Benzodiazepines for Alcohol Withdrawal in the Elderly and in Patients With Liver Disease

A Comparison of Injectable Diazepam and Lorazepam in the Goal-Directed Management of Severe Alcohol Withdrawal

BACKGROUND

Benzodiazepines are the gold standard for treatment of alcohol withdrawal, yet the selection of a preferred benzodiazepine is limited due to a lack of comparative studies.

OBJECTIVES

The primary objective of this study was to compare the efficacy and safety of injectable lorazepam (LZP) and diazepam (DZP) in the treatment of severe alcohol withdrawal syndrome (AWS).

METHODS

Retrospective cohort study of adult patients admitted to an intensive care unit with a primary diagnosis of AWS. Subjects who received at least 12 LZP equivalent units (LEU) of injectable DZP or LZP within 24 hours of initiation of the severe AWS protocol were included. The primary outcome was time with Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) scores at goal over the first 24 hours of treatment.

RESULTS

A total of 191 patients were included (DZP n = 89, LZP n = 102). Time with CIWA-Ar scores at goal during the first 24 hours was similar between groups (DZP 12 hours [interquartile range, IQR, = 9-15] vs LZP 14 hours [IQR = 10-17]), P = 0.06). At 24 hours, LEU requirement was similar (DZP 40 [IQR = 22-78] vs LZP 32 [IQR = 18-56], P = 0.05). Drug cost at 24 hours was higher in the DZP group ($204.6 [IQR = 112.53-398.97] vs $8 [IQR = 4.5-14], P < 0.01).

CONCLUSION AND RELEVANCE

DZP or LZP are equally efficacious for the treatment of severe AWS. LZP may be preferred due to cost but both medications can be used interchangeably based on availability.

Phenobarbital use in benzodiazepine and z-drug detoxification: a single-centre 15-year observational retrospective study in clinical practice

Given the increase in benzodiazepine (BZD) and Z-drug (ZD) use disorder, this study described the use of phenobarbital (PHB) as detoxification in clinical practice. A 15-year observational retrospective study was performed on medical records of BZD-ZD use disorder patients detoxified with PHB at the Toxicology Unit and Poison Centre, Careggi University Hospital, Florence (Italy). A multivariate logistic regression was used to estimate odd ratios (ORs) and related 95% confidence intervals (CI) of "treatment failure" considering demographic and pharmacological characteristics. "Hospitalisation length", "PHB discharge dose", and "BZD-ZD free status" at discharge were also calculated. During detoxification, out of 355 patients (57% of men), with a mean age of 42.92 years, only 20 (5.6%) treatment failures were recorded: 19 were discharged against medical advice or due to misbehaviour, and only one for PHB-related non-serious skin rash. Analysis showed a higher probability to be BZD-ZD free at discharge for subjects who reported to be employed (OR 2.29; CI 95% 1.00-5.24), for those who abused oral drops of BZD-ZD (OR 2.16, CI 1.30-3.59), and for those treated with trazodone (OR 2.86, CI 1.14-7.17) during hospital stay. A hospitalisation length of > 7 days was observed for patients with opioid maintenance therapy (OR 2.07, CI 1.20-3.58) for substance use disorder, and for those treated with more than 300 mg/day of PHB equivalents at hospital admission (OR 1.68, CI 1.03-2.72). Our results suggested that PHB can be considered a valuable detoxification option for different types of BZD and ZD use disorder patients.

New Australian guidelines for the treatment of alcohol problems: an overview of recommendations

OF RECOMMENDATIONS AND LEVELS OF EVIDENCE

Chapter 2: Screening and assessment for unhealthy alcohol use Screening Screening for unhealthy alcohol use and appropriate interventions should be implemented in general practice (Level A), hospitals (Level B), emergency departments and community health and welfare settings (Level C). Quantity-frequency measures can detect consumption that exceeds levels in the current Australian guidelines (Level B). The Alcohol Use Disorders Identification Test (AUDIT) is the most effective screening tool and is recommended for use in primary care and hospital settings. For screening in the general community, the AUDIT-C is a suitable alternative (Level A). Indirect biological markers should be used as an adjunct to screening (Level A), and direct measures of alcohol in breath and/or blood can be useful markers of recent use (Level B). Assessment Assessment should include evaluation of alcohol use and its effects, physical examination, clinical investigations and collateral history taking (Level C). Assessment for alcohol-related physical problems, mental health problems and social support should be undertaken routinely (GPP). Where there are concerns regarding the safety of the patient or others, specialist consultation is recommended (Level C). Assessment should lead to a clear, mutually acceptable treatment plan which specifies interventions to meet the patient's needs (Level D). Sustained abstinence is the optimal outcome for most patients with alcohol dependence (Level C). Chapter 3: Caring for and managing patients with alcohol problems: interventions, treatments, relapse prevention, aftercare, and long term follow-up Brief interventions Brief motivational interviewing interventions are more effective than no treatment for people who consume alcohol at risky levels (Level A). Their effectiveness compared with standard care or alternative psychosocial interventions varies by treatment setting. They are most effective in primary care settings (Level A). Psychosocial interventions Cognitive behaviour therapy should be a first-line psychosocial intervention for alcohol dependence. Its clinical benefit is enhanced when it is combined with pharmacotherapy for alcohol dependence or an additional psychosocial intervention (eg, motivational interviewing) (Level A). Motivational interviewing is effective in the short term and in patients with less severe alcohol dependence (Level A). Residential rehabilitation may be of benefit to patients who have moderate-to-severe alcohol dependence and require a structured residential treatment setting (Level D). Alcohol withdrawal management Most cases of withdrawal can be managed in an ambulatory setting with appropriate support (Level B). Tapering diazepam regimens (Level A) with daily staged supply from a pharmacy or clinic are recommended (GPP). Pharmacotherapies for alcohol dependence Acamprosate is recommended to help maintain abstinence from alcohol (Level A). Naltrexone is recommended for prevention of relapse to heavy drinking (Level A). Disulfiram is only recommended in close supervision settings where patients are motivated for abstinence (Level A). Some evidence for off-label therapies baclofen and topiramate exists, but their side effect profiles are complex and neither should be a first-line medication (Level B). Peer support programs Peer-led support programs such as Alcoholics Anonymous and SMART Recovery are effective at maintaining abstinence or reductions in drinking (Level A). Relapse prevention, aftercare and long-term follow-up Return to problematic drinking is common and aftercare should focus on addressing factors that contribute to relapse (GPP). A harm-minimisation approach should be considered for patients who are unable to reduce their drinking (GPP). Chapter 4: Providing appropriate treatment and care to people with alcohol problems: a summary for key specific populations Gender-specific issues Screen women and men for domestic abuse (Level C). Consider child protection assessments for caregivers with alcohol use disorder (GPP). Explore contraceptive options with women of reproductive age who regularly consume alcohol (Level B). Pregnant and breastfeeding women Advise pregnant and breastfeeding women that there is no safe level of alcohol consumption (Level B). Pregnant women who are alcohol dependent should be admitted to hospital for treatment in an appropriate maternity unit that has an addiction specialist (GPP). Young people Perform a comprehensive HEEADSSS assessment for young people with alcohol problems (Level B). Treatment should focus on tangible benefits of reducing drinking through psychotherapy and engagement of family and peer networks (Level B). Aboriginal and Torres Strait Islander peoples Collaborate with Aboriginal or Torres Strait Islander health workers, organisations and communities, and seek guidance on patient engagement approaches (GPP). Use validated screening tools and consider integrated mainstream and Aboriginal or Torres Strait Islander-specific approaches to care (Level B). Culturally and linguistically diverse groups Use an appropriate method, such as the "teach-back" technique, to assess the need for language and health literacy support (Level C). Engage with culture-specific agencies as this can improve treatment access and success (Level C). Sexually diverse and gender diverse populations Be mindful that sexually diverse and gender diverse populations experience lower levels of satisfaction, connection and treatment completion (Level C). Seek to incorporate LGBTQ-specific treatment and agencies (Level C). Older people All new patients aged over 50 years should be screened for harmful alcohol use (Level D). Consider alcohol as a possible cause for older patients presenting with unexplained physical or psychological symptoms (Level D). Consider shorter acting benzodiazepines for withdrawal management (Level D). Cognitive impairment Cognitive impairment may impair engagement with treatment (Level A). Perform cognitive screening for patients who have alcohol problems and refer them for neuropsychological assessment if significant impairment is suspected (Level A).

SUMMARY OF KEY RECOMMENDATIONS AND LEVELS OF EVIDENCE

Chapter 5: Understanding and managing comorbidities for people with alcohol problems: polydrug use and dependence, co-occurring mental disorders, and physical comorbidities Polydrug use and dependence Active alcohol use disorder, including dependence, significantly increases the risk of overdose associated with the administration of opioid drugs. Specialist advice is recommended before treatment of people dependent on both alcohol and opioid drugs (GPP). Older patients requiring management of alcohol withdrawal should have their use of pharmaceutical medications reviewed, given the prevalence of polypharmacy in this age group (GPP). Smoking cessation can be undertaken in patients with alcohol dependence and/or polydrug use problems; some evidence suggests varenicline may help support reduction of both tobacco and alcohol consumption (Level C). Co-occurring mental disorders More intensive interventions are needed for people with comorbid conditions, as this population tends to have more severe problems and carries a worse prognosis than those with single pathology (GPP). The Kessler Psychological Distress Scale (K10 or K6) is recommended for screening for comorbid mental disorders in people presenting for alcohol use disorders (Level A). People with alcohol use disorder and comorbid mental disorders should be offered treatment for both disorders; care should be taken to coordinate intervention (Level C). Physical comorbidities Patients should be advised that alcohol use has no beneficial health effects. There is no clear risk-free threshold for alcohol intake. The safe dose for alcohol intake is dependent on many factors such as underlying liver disease, comorbidities, age and sex (Level A). In patients with alcohol use disorder, early recognition of the risk for liver cirrhosis is critical. Patients with cirrhosis should abstain from alcohol and should be offered referral to a hepatologist for liver disease management and to an addiction physician for management of alcohol use disorder (Level A). Alcohol abstinence reduces the risk of cancer and improves outcomes after a diagnosis of cancer (Level A).

Ambulatory detoxification in alcohol use disorder and opioid use disorder

Ambulatory detoxification in alcohol use disorder and opioid use disorder is an important component in the management of patients experiencing withdrawal symptoms from alcohol or opioids. The goal of withdrawal management is ultimately to provide each patient with comfort and safety. Having the knowledge of the possible signs and symptoms of intoxication and withdrawal assists providers to institute the most appropriate treatment protocol and setting for the patient. Pharmacists play a vital role in choosing appropriate therapeutic management options for common or complex clinical situations involving ambulatory detoxification from alcohol and opioids. Ambulatory detoxification serves as an appealing option to many patients and helps save the limited inpatient resources that many institutions have for those patients with more severe withdrawal presentations.

Alcohol and the Hospitalized Patient

Alcohol use is a common social and recreational activity in our society. Misuse of alcohol can lead to significant medical comorbidities that can affect essentially every organ system and lead to high health care costs and utilization. Heavy alcohol use across the spectrum from binge drinking and intoxication to chronic alcohol use disorder can lead to high morbidity and mortality both in the long and short term. Recognizing and treating common neurologic, gastrointestinal, and hematological manifestations of excess alcohol intake are essential for those who care for hospitalized patients. Withdrawal is among the most common and dangerous sequela associated with alcohol use disorder.

Benzodiazepine Use Is Associated With an Increased Risk of Neurocognitive Impairment in People Living With HIV

OBJECTIVE

Despite potential for dependence and adverse neurological effects, long-term benzodiazepine (BZD) use is common among people living with HIV (PLWH). As PLWH are at risk for central nervous system dysfunction, we retrospectively examined the association between BZD use and HIV-associated neurocognitive impairment (NCI).

METHODS

Three hundred six PLWH underwent comprehensive neurobehavioral evaluations. Current BZD use (BZD+) was determined through self-report. Using propensity scores, 153 BZD- individuals were matched to 153 BZD+ participants on demographics and medical comorbidities. Multiple regression models examined NCI and demographically adjusted neurocognitive T-scores as a function of BZD status, adjusting for estimated premorbid ability, current affective symptoms, and nadir CD4 count. Secondary analyses explored neurocognitive correlates of positive BZD urine toxicology screens (TOX+) and specific BZD agents.

RESULTS

Median duration of BZD use was 24 months. Current BZD use related to higher likelihood of NCI (odds ratio = 2.13, P = 0.003) and poorer global (d = -0.28, P = 0.020), processing speed (d = -0.23, P = 0.047), and motor T-scores (d = -0.32, P = 0.008). Compared with BZD-/TOX-, BZD+/TOX+ exhibited additional decrements in executive function (d = -0.48, P = 0.013), working memory (d = -0.49, P = 0.011), and delayed recall (d = -0.41, P = 0.032). For individual agents, diazepam, lorazepam, and alprazolam were most strongly associated with NCI (odds ratios >2.31).

DISCUSSION

BZD use may elevate risk for NCI in PLWH, potentially through diffuse neurocognitive slowing and acute compromise of recall and higher-order capacities. These effects are robust to psychosocial and HIV-specific factors and occur in comparison with a tightly matched BZD- group. Prospective and interventional studies should evaluate causal associations between NCI and BZD use and explore treatment alternatives to BZDs in PLWH.

Takotsubo cardiomyopathy triggered by delirium tremens in a cirrhotic patient with acute-on-chronic liver failure: A case report

A 64-year-old cirrhotic woman was admitted for alcoholic hepatitis associated with renal failure. Subsequently, she displayed symptoms of alcohol withdrawal progressing to delirium tremens. During hospitalization, she developed acute respiratory distress. The electrocardiogram showed diffuse anteroseptal ST elevation. Transthoracic echocardiography revealed systolic left ventricular apical balloon-like dilation, hypokinesis of the left ventricular mid- and apical segments, and a left ventricular ejection fraction of 30%. Coronary angiography was normal and led to the diagnosis of Takotsubo cardiomyopathy. This report describes a singular case of Takotsubo cardiomyopathy precipitated by delirium tremens in a cirrhotic patient with acute-on-chronic liver failure.

Psychological predictors of benzodiazepine discontinuation among older adults: Results from the PASSE 60

BACKGROUND

Long-term benzodiazepine (BZD) use among seniors is mostly inappropriate and associated with adverse health outcomes. To prevent these consequences, withdrawal is crucial, yet knowledge is limited about what predicts BZD discontinuation. Until now, most studies have focused on sociodemographic and BZD intake factors as predictors while neglecting psychological factors. This research addresses this issue by studying how the intensity of depressive symptoms, social support satisfaction, self-perceived competence in the ability to withdraw, and overall quality of sleep predict discontinuation in long-term older consumers.

METHOD

Seventy-three participants aged 60 years and older were enrolled in this study. There were four time measures: before discontinuation (T1), after (T2), 3 months after (T3), and 12 months after (T4). Data were collected in the "Programme d'Aide du Succès au SEvrage" (PASSE-60+) study.

RESULTS

Social support satisfaction predicted discontinuation at T2 and T4. Self-perceived competence in the ability to withdraw and depressive symptoms predicted discontinuation at T4. This later prediction was counterintuitive; higher depressive symptoms at T1 were linked with higher discontinuation success. BZD intake factors (length of use and dose) were good predictors for short term discontinuation. Psychological factors were moderate predictors for short term and good predictors for long term discontinuation.

CONCLUSION

Psychological factors are good predictors of discontinuation and are better predictors than BZD intake factors of long-term discontinuation. Discontinuation programs should focus on social support and self-perceived competence to improve their efficacy. Further studies are needed to acquire a more complete picture of the psychological predictors of discontinuation success. ClinicalTrials.gov Identifier: NCT02281175.

Alcohol-related liver disease. Clinical practice guidelines. Consensus document sponsored by AEEH

Alcohol-related liver disease (ARLD) is the most prevalent cause of advanced liver disease and liver cirrhosis in Europe, including Spain. According to the World Health Organization the fraction of liver cirrhosis attributable to alcohol use in Spain is 73.8% among men and 56.3% among women. ARLD includes various stages such as steatohepatitis, cirrhosis and hepatocellular cancer. In addition, patients with underlying ARLD and heavy alcohol intake may develop alcoholic hepatitis, which is associated with high mortality. To date, the only effective treatment to treat ARLD is prolonged withdrawal. There are no specific treatments, and the only treatment that increases life expectancy in alcoholic hepatitis is prednisolone. For patients with alcoholic hepatitis who do not respond to treatment, some centres offer the possibility of an early transplant. These clinical practice guidelines aim to propose recommendations on ARLD taking into account their relevance as a cause of advanced chronic liver disease and liver cirrhosis in our setting. This paper aims to answer the key questions for the clinical practice of Gastroenterology, Hepatology, as well as Internal Medicine and Primary Health Centres, making the most up-to-date information regarding the management and treatment of ARLD available to health professionals. These guidelines provide evidence-based recommendations for the clinical management of this disease.

Psychopharmacology in transplantation medicine

Organ transplantation has become a well-established treatment option in patients with end-stage organ diseases. Although quality of life has markedly improved, psychiatric disorders before and after transplantation are more frequent compared to the general population. Psychopharmacological treatment is recommended for almost all mental disorders according to current guidelines, but may pose particular problems in organ transplant patients. Changes in the metabolism and elimination of drugs during organ insufficiency, drug interactions, and overlapping side effects between psychopharmacological and immunosuppressive drugs are challenging problems in clinical management. Furthermore, questions frequently arise concerning the use of psychopharmacological treatment options for sleeping and anxiety disorders. This article reviews psychopharmacology in organ transplant patients, with particular attention to frequent psychiatric disorders observed in the disease course of end-stage organ diseases.

Benzodiazepines and risk for hepatic encephalopathy in patients with cirrhosis and ascites

Background

There is limited evidence to support the belief that benzodiazepines increase cirrhosis patients' risk of hepatic encephalopathy (HE).

Objective

We aimed to examine the association between benzodiazepine use and HE development in cirrhosis patients.

Methods

We used data on 865 cirrhosis patients with ascites from three trials to study the effect of benzodiazepine use on development of first-time HE. For each patient, we classified periods of benzodiazepine use by the number of days since initiation. We used Cox regression to compare the risk of HE in current benzodiazepine users vs. non-users adjusting for confounders.

Results

Cirrhosis patients were not at increased risk of HE for the first two days of benzodiazepine use, but then faced a five-fold increased risk of HE during days 3 to 10 of benzodiazepine use. The risk of HE was not increased for those who had been using benzodiazepines for more than 28 days.

Conclusion

Cirrhosis patients who had begun using benzodiazepines between 3 and 10 days previously had a markedly increased risk of developing first-time HE. Cirrhosis patients who had been using benzodiazepines for just one or two days or continued use for more than 28 days did not have such an excess risk.

Pharmacotherapy for Alcohol Dependence: The 2015 Recommendations of the French Alcohol Society, Issued in Partnership with the European Federation of Addiction Societies

BACKGROUND

The latest French good practice recommendations (GPRs) for the screening, prevention, and treatment of alcohol misuse were recently published in partnership with the European Federation of Addiction Societies (EUFAS). This article aims to synthesize the GPRs focused on the pharmacotherapy of alcohol dependence.

METHODS

A four-member European steering committee defined the questions that were addressed to an 18-member multiprofessional working group (WG). The WG developed the GPRs based on a systematic, hierarchical, and structured literature search and submitted the document to two review processes involving 37 French members from multiple disciplines and 5 non-French EUFAS members. The final GPRs were graded A, B, or C, or expert consensus (EC) using a reference recommendation grading system.

RESULTS

The treatment of alcohol dependence consists of either alcohol detoxification or abstinence maintenance programs or drinking reduction programs. The therapeutic objective is the result of a decision made jointly by the physician and the patient. For alcohol detoxification, benzodiazepines (BZDs) are recommended in first-line (grade A). BZD dosing should be guided by regular clinical monitoring (grade B). Residential detoxification is more appropriate for patients with a history of seizures, delirium tremens, unstable psychiatric comorbidity, or another associated substance use disorder (grade B). BZDs are only justified beyond a 1-week period in the case of persistent withdrawal symptoms, withdrawal events or associated BZD dependence (grade B). BZDs should not be continued for more than 4 weeks (grade C). The dosing and duration of thiamine (vitamin B1) during detoxification should be adapted to nutritional status (EC). For relapse prevention, acamprosate and naltrexone are recommended as first-line medications (grade A). Disulfiram can be proposed as second-line option in patients with sufficient information and supervision (EC). For reducing alcohol consumption, nalmefene is indicated in first line (grade A). The second-line prescription of baclofen, up to 300 mg/day, to prevent relapse or reduce drinking should be carried out according to the "temporary recommendation for use" measure issued by the French Health Agency (EC). During pregnancy, abstinence is recommended (EC). If alcohol detoxification is conducted during pregnancy, BZD use is recommended (grade B). No medication other than those for alcohol detoxification should be initiated in pregnant or breastfeeding women (EC). In a stabilized pregnant patient taking medication to support abstinence, the continuation of the drug should be considered on a case-by-case basis, weighing the benefit/risk ratio. Only disulfiram should be always stopped, given the unknown risks of the antabuse effect on the fetus (EC). First-line treatments to help maintain abstinence or reduce drinking are off-label for people under 18 years of age and should thus be considered on a case-by-case basis after the repeated failure of psychosocial measures alone (EC). Short half-life BZDs should be preferred for the detoxification of elderly patients (grade B). The initial doses of BZDs should be reduced by 30 to 50% in elderly patients (EC). In patients with chronic alcohol-related physical disorders, abstinence is recommended (EC). Any antidepressant or anxiolytic medication should be introduced after a psychiatric reassessment after 2-4 weeks of alcohol abstinence or low-risk use (grade B). A smoking cessation program should be offered to any smokers involved in an alcohol treatment program (grade B).

Addition of dexmedetomidine to benzodiazepines for patients with alcohol withdrawal syndrome in the intensive care unit: a randomized controlled study

Background

Dexmedetomidine (DEX) is a centrally acting alpha-2-adrenoceptor agonist that has potential in the management of alcohol withdrawal syndrome (AWS) owing to its ability to produce arousable sedation and to inhibit the adrenergic system without respiratory depression. The objective of this randomized controlled study was to evaluate whether addition of DEX to benzodiazepine (BZD) therapy is effective and safe for AWS patients in the intensive care unit (ICU).

Methods

Eligible participants were randomly assigned to intervention (Group D; n = 36) or control (Group C; n = 36). In Group D, DEX infusion was started at a dose of 0.2–1.4 μg/kg/h and titrated to achieve the target sedation level (–2 to 0 on the Richmond Agitation Sedation Scale (RASS)) with symptom-triggered BZD (10 mg diazepam bolus) was used as needed. Patients in Group C received only symptom-triggered 10 mg boluses of diazepam. The primary efficacy outcomes were 24-h diazepam consumption and cumulative diazepam dose required over the course of the ICU stay; secondary outcomes included length of ICU stay, sedation and communication quality and haloperidol requirements.

Results

Median 24-h diazepam consumption during the study was significantly lower in Group D (20 vs. 40 mg, p < 0.001), as well as median cumulative diazepam dose during the ICU stay (60 vs. 90 mg, p < 0.001). The median percentage of time in the target sedation range was higher in Group D (median 90 % (90–95) vs. 64.5 % (60–72.5; p < 0.001). DEX infusion was also associated with better nurse-assessed patient communication (<0.001) and fewer patients requiring haloperidol treatment (2 vs. 10 p = 0.02). One patient in Group D and four in Group C were excluded owing to insufficient control of AWS symptoms and use of additional sedatives (p = 0.36). There were no severe adverse events in either group. Spontaneous breathing remained normal in all patients. Bradycardia was a common adverse event in Group D (10 vs. 2; p = 0.03).

Conclusions

DEX significantly reduced diazepam requirements in ICU patients with AWS and decreased the number of patients who required haloperidol for severe agitation and hallucinations. DEX use was also associated with improvement in diverse aspects of sedation quality and the quality of patient communication.

Trial registration: ClinicalTrials.gov: NCT02496650

Identification and management of alcohol withdrawal syndrome

Symptoms of alcohol withdrawal syndrome (AWS) may develop within 6-24 h after the abrupt discontinuation or decrease of alcohol consumption. Symptoms can vary from autonomic hyperactivity and agitation to delirium tremens. The gold-standard treatment for AWS is with benzodiazepines (BZDs). Among the BZDs, different agents (i.e., long-acting or short-acting) and different regimens (front-loading, fixed-dose or symptom-triggered) may be chosen on the basis of patient characteristics. Severe withdrawal could require ICU admission and the use of barbiturates or propofol. Other drugs, such as α2-agonists (clonidine and dexmetedomidine) and β-blockers can be used as adjunctive treatments to control neuroautonomic hyperactivity. Furthermore, neuroleptic agents can help control hallucinations. Finally, other medications for the treatment for AWS have been investigated with promising results. These include carbamazepine, valproate, sodium oxybate, baclofen, gabapentin and topiramate. The usefulness of these agents are discussed.

Exploring diazepam's effect on hemodynamic responses of mouse brain tissue by optical spectroscopic imaging

In this study, a simple duel-optical spectroscopic imaging apparatus capable of simultaneously determining relative changes in brain oxy-and deoxy-hemoglobin concentrations was used following administration of the anxiolytic compound diazepam in mice with strong dominant (Dom) and submissive (Sub) behavioral traits. Three month old mice (n = 30) were anesthetized and after 10 min of baseline imaging, diazepam (1.5 mg/kg) was administered and measurements were taken for 80 min. The mouse head was illuminated by white light based LED's and diffused reflected light passing through different channels, consisting of a bandpass filter and a CCD camera, respectively, was collected and analyzed to measure the hemodynamic response. This work's major findings are threefold: first, Dom and Sub animals showed statistically significant differences in hemodynamic response to diazepam administration. Secondly, diazepam was found to more strongly affect the Sub group. Thirdly, different time-series profiles were observed post-injection, which can serve as a possible marker for the groups' differentiation. To the best of our knowledge, this is the first report on the effects of an anxiolytic drug on brain hemodynamic responses in mice using diffused light optical imaging.

Inpatient management of acute alcohol withdrawal syndrome

Alcohol withdrawal is a common condition encountered in the hospital setting after abrupt discontinuation of alcohol in an alcohol-dependent individual. Patients may present with mild symptoms of tremulousness and agitation or more severe symptoms including withdrawal seizures and delirium tremens. Management revolves around early identification of at-risk individuals and symptom assessment using a validated tool such as the revised Clinical Institute Withdrawal Assessment for Alcohol score. Benzodiazepines remain the mainstay of treatment and can be administered using a front-loading, fixed-dose, or symptom-triggered approach. Long-acting benzodiazepines such as chlordiazepoxide or diazepam are commonly used and may provide a smoother withdrawal than shorter-acting benzodiazepines, but there are no data to support superiority of one benzodiazepine over another. Elderly patients or those with significant liver disease may have increased accumulation and decreased clearance of the long-acting benzodiazepines, and lorazepam or oxazepam may be preferred in these patients. Patients with symptoms refractory to high doses of benzodiazepines may require addition of a rescue medication such as phenobarbital, propofol or dexmedetomidine. Anticonvulsants (carbamazepine, valproate, gabapentin) may have a role in the management of mild to moderate withdrawal. Other medications such as β-antagonists or neuroleptics may offer additional benefit in select patients but should not be used a monotherapy.

FT-IR, FT-Raman spectra and ab initio HF and DFT calculations of 7-chloro-5-(2-chlorophenyl)-3-hydroxy-2,3-dihydro-1H-1,4-benzodiazepin-2-one

The Fourier Transform infrared and Fourier Transform Raman spectra of 7-chloro-5 (2-chlorophenyl)-3-hydroxy-2,3-dihydro-1H-1,4-benzodiazepin-2-one (7C3D4B) were recorded in the regions 4000-400 and 4000-100 cm(-1), respectively. The appropriate theoretical spectrograms for the IR and Raman spectra of the title molecule were also constructed. The calculated results show that the predicted geometry can well reproduce the structural parameters. Predicted vibrational frequencies have been assigned and compared with experimental IR spectra and they supported each other. Stability of the molecule arising from hyperconjugative interactions, charge delocalization and intramolecular hydrogen bond-like weak interaction has been analyzed using natural bond orbital (NBO) analysis by using B3LYP/6-31G(d,p) method. The results show that electron density (ED) in the σ* and π* antibonding orbitals and second-order delocalization energies E(2) confirm the occurrence of intramolecular charge transfer (ICT) within the molecule. The first order hyperpolarizability (βtotal) of this molecular system and related properties (β, μ, and Δα) are calculated using HF/6-31G(d,p) and B3LYP/6-31G(d,p) methods based on the finite-field approach.

1,4-Benzodiazepin-2-ones in medicinal chemistry

1,4-Benzodiazepin-2-ones have applications in many areas of medicinal chemistry that are not restricted to 'classical' CNS treatments such as sedatives, epilepsy and muscle relaxants. We will describe selected examples of 1,4-benzodiazepin-2-ones in other areas of medicinal chemistry including uses as G-protein-coupled receptor antagonists, enzyme inhibitors and anticancer agents. Examples from our group will mainly show the use of palladacycle complexes of 1,4-benzodiazepin-2-ones as anticancer agents.

Levetiracetam for the treatment of alcohol withdrawal syndrome: a multicenter, prospective, randomized, placebo-controlled trial

BACKGROUND

Treatment of alcohol withdrawal syndrome (AWS) with benzodiazepines is limited by risk of abuse, intoxication, respiratory problems, and liver toxicity. Alternatives such as carbamazepine and valproate may also have safety problems, such as hepatotoxicity or central nervous adverse effects. We therefore investigated the safety and efficacy of levetiracetam (LV), a newer antiepileptic with a potentially favorable adverse-effect profile, for the treatment of AWS.

METHODS

One hundred six patients were enrolled in a prospective, randomized, double-blind, multicenter, placebo-controlled trial. Levetiracetam was administered in a fixed dose schedule over 6 days. Diazepam was added when symptom triggered as rescue medication. Severity of the AWS was measured with the AWS and Clinical Institute Withdrawal Assessment Scale.

RESULTS

Although tolerability and safety data were similar in the LV group when compared with placebo, the total daily and weekly dose of diazepam as rescue medication and the severity of alcohol withdrawal symptoms did not differ significantly between groups.

CONCLUSION

Our data so far do not support an additional effect of LV on the reduction of alcohol withdrawal symptoms.

Psychiatric consultation for post-liver-transplantation patients

AIM

This report describes the clinical characteristics of referral inpatients who received liver transplantation and the surgeon's concordance with the psychiatric consultation.

METHODS

During a 4-year period, psychiatric consultation was arranged for 30 post-liver-transplantation inpatients at Kaohsiung Chang Gung Memorial Hospital. A psychiatrist assessed these patients and made psychiatric diagnoses according to the Diagnostic and Statistical Manual, 4th edition. The clinical data were routinely collected via modified MICRO-CARES software. At the end of the 4-year study period, all the medical records of these 30 inpatients were reviewed.

RESULTS

Psychiatric diagnosis was made in 70% of the patients (n = 21) in three major categories, including delirious state (n = 8), depressive disorder (n = 5), and anxiety/dyssomnia (n = 8). All these conditions were improved by psychiatric management. We found that the consultee's concordance with recommended drug prescriptions was high with antidepressants in depressive patients and low with antipsychotics in patients with delirium. Moreover, anxiolytics were frequently prescribed in post-transplant inpatients before psychiatric consultation.

CONCLUSION

These findings suggest that psychiatric consultation is beneficial to inpatients after liver transplantation, especially those with depression and delirium.

Nitric oxide mediates the inhibitory effect of ethanol on the motility of isolated longitudinal muscle of proximal colon in rats

The aim of the present study was to investigate the effect of ethanol on colon motility in rats and to test the possibility that nitric oxide (NO) mediates this effect. Proximal colon longitudinal muscle strips (LM) (8 x 3 mm) cut parallel to the longitudinal muscle fibres of the colon were isolated and mounted in an organ bath. Ethanol (0.57, 0.87 and 1.30 mmol L(-1)) dose-dependently inhibited the motility of LM. Longitudinal muscle strips from female rats were more sensitive to the inhibitory effect of ethanol than that from male rats. L-NAME (N-nitro-L-arginine methyl ester) (100 micromol L(-1)), AG (aminoguanidine) (10 micromol L(-1)), ODQ (1H-[1,2,4]Oxadiazolo[4,3-a]quinoxalin-1-one) (10 micromol L(-1)) and PTIO (2-Phenyl-4,4,5,5-tetramethylimidazoline-1-oxyl 3-oxide) (200 micromol L(-1)) partly blocked the inhibitory effect of ethanol on LM. Pretreatment with L-NAME, AG, ODQ and PTIO abolished the sex difference of the inhibitory effect of ethanol on LM. Tetrodotoxin (TTX) (10 micromol L(-1)) partly blocked the inhibitory effect but did not influence the sex difference. The relaxation of LM induced by SNP (sodium nitroprusside) (0.1-10 micromol L(-1)) in female rats was greater than that in male rats. In conclusion, ethanol inhibited the colon motility in vitro. This inhibitory effect on LM was mediated by NO through the iNOS - NO - cGMP pathway.

Management of psychiatric problems in critically ill patients

Critical care units have become essential elements in modern medicine. These units reflect the highest levels of scientific and technological advance in medicine. Within these units, however, lie significant psychiatric challenges for patients and staff. This article examines the identification and treatment of the most frequent psychiatric problems facing patients entering critical care units, including delirium, depression and anxiety. These conditions are important to address in order to decrease patient suffering and improve morbidity and mortality. The article also addresses some of the most common staff stressors encountered in working in these units. Managing these stressors makes the critical care unit a place where staff can flourish instead of burning out. Specific techniques may help the staff deal with the complex medical, psychological, and ethical issues found in these units in an empathic, compassionate, and well-balanced manner that allows ongoing work satisfaction.

Pharmacological management of aggression and violence

The pharmacological management of violence and aggression is a common and substantial clinical dilemma in the emergency psychiatric situation. A literature search was conducted through PubMed and using the Cochrane Library. This was followed by a manual search of selected literature. Randomised controlled trials were sought that specifically addressed the acute situation, rather than the ongoing management of chronic conditions. There was a paucity of well-controlled data and insufficient evidence to support the use of many agents in emergency situations. Many studies had considerable limitations making comparison difficult. Efficacy data for a range of treatment options exists, including the use of classical and atypical anti-psychotic agents, benzodiazepines and combination therapies. Clinical risk, tolerability and environmental factors need to form part of a careful and considered judgement in the choice of treatment. Safety, tolerability and the potential for a positive experience are major considerations, thus paving the way for long term compliance.

Management of Acute Alcohol Withdrawal in the Inpatient Setting

Collaborative drug therapy management (CDTM) is a method for developing a patient-centered practice in which the pharmacist's activities are integrated with those of other health care providers. The goals of this continuing feature are to refine the concept of CDTM and provide patient-care applications from the authors' experience in Washington state. Questions or suggestions should be addressed to Timothy S. Fuller, FASHP, Fuller and Associates, 1948 Boyer Avenue East, Seattle, WA 98112-2924 (tel.206-860-8308). E-mail: timfuller@kendra.com

Alcohol-related diarrhea

Abstract Alcohol generates a large caloric yield without supplying any essential nutrients; alcoholics may thus maintain body weight while suffering from malnutrition. In addition, diarrhea is a common complaint of both acute and chronic alcoholics. Here, we review the effects of alcohol on gastrointestinal morphology, function, its nervous system and motility. Acute morphological changes such as erosions, inflammatory cell infiltrations and microvascular changes are seen in the stomach and small intestine in acute alcoholics. In addition, atrophic gastritis, reduced villous height and decreased mucosal surface area of the small intestine have been described in chronic alcoholics. Acute administration of alcohol inhibits absorption of nutrients and fluids, and can stimulate secretion of water and electrolytes. Bacterial overgrowth in the proximal small intestine and decreased pancreatic secretions have been also described in chronic alcoholics. The well-known deleterious effects of alcohol on the central nervous system raise the possibility of similar acute and chronic effects of the enteric nervous system. Such effects could alter motility and transit. Indeed, esophageal dysmotility and delayed gastric emptying have been observed with high concentrations of alcohol in experimental studies and in chronic alcoholics. Small bowel motility and transit may be abnormal in both acute and chronic alcoholics, and colonic propulsive motility is increased after acute administration of alcohol. Any, or all, of these changes in gastrointestinal functions may contribute to diarrhea in acute binge drinkers and chronic alcoholics. Unfortunately, there is a lack of systematic studies of the pathophysiology of alcohol abuse, and an integrating concept of the diarrhea of alcoholics is still not possible.

Effects of oxazepam and acetaminophen on cicletanine metabolism in rat hepatocytes and liver microsomes

Cicletanine, a racemic furopyridine derivative synthesized as racemate, is used as an antihypertensive agent. Its two enantiomers are involved in the pharmacological effects of the drug. Cicletanine is metabolized by conjugation enzyme systems (phase II) into sulfoconjugated or glucuroconjugated enantiomers. As oxazepam and acetaminophen are widely prescribed, especially to elderly patients, these two drugs may be co-administered with cicletanine. The metabolic profile and the kinetics of biotransformation were studied by using rat hepatocytes and liver microsomes. Cicletanine was extensively metabolized by rat hepatocytes. More than 80% of the drug was biotransformed after a 3 h incubation. The formation of glucuroconjugated metabolites was characterized by the following kinetic parameters, i.e. Vmax = 2.05 +/- 0.21 nmol/min/mg protein and Km = 287 +/- 6.7 microM for (-)-cicletanine, and Vmax = 1.44 +/- 0.12 nmol/min/mg protein and K(m) = 171 +/- 4.1 microM for (+)-cicletanine. Oxazepam inhibited the glucuronidation of cicletanine in both rat hepatocytes and liver microsomes with a competitive-type inhibition, i.e. K(i) = 129 +/- 7.5 and 152 +/- 19.7 microM for (-)-cicletanine and (+)-cicletanine, respectively. The co-incubation of acetaminophen with cicletanine showed that only sulfoconjugation was inhibited in rat hepatocytes. Glucuronidation was not modified by acetaminophen. As natriuric activity is due to sulfoconjugated (+)-cicletanine, acetaminophen could potentially modulate in vivo the pharmacological effect of cicletanine. The data of the in vitro study reported here suggested an interaction between cicletanine and oxazepam or cicletanine and acetaminophen. However, the clinical impact of such a drug interaction needs further evaluation.

Effect of diazepam on growth hormone secretion in abstinent alcoholic men

The present study was performed in order to establish, with a simple and safe neuroendocrinological test, whether alcoholism is associated with alterations in sensitivity to benzodiazepines. For this purpose, we tested the stimulatory effects of diazepam on GH secretion. An intravenous bolus of 10 mg diazepam was injected in 51 (33-51-year-old) alcoholic men after at least 5 weeks of abstinence and in 20 age- and weight-matched normal controls. On a different occasion, a control test with placebo (physiological saline) was performed in the same subjects. Diazepam but not placebo administration induced a striking increase of GH secretion in the normal controls. In contrast, neither diazepam nor placebo treatment significantly changed the basal serum GH levels in alcoholic men. These data show that alcoholism is associated with disrupted benzodiazepine activity on the hypothalamic-pituitary control of GH secretion. The simplicity of the diazepam GH-releasing test makes the drug suitable for clinical research in alcoholism.