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Colvard M. Concurrent opioid and alcohol withdrawal management. Ment Health Clin 2023; 13:268-275. [PMID: 38058596 PMCID: PMC10696169 DOI: 10.9740/mhc.2023.12.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 08/04/2023] [Indexed: 12/08/2023] Open
Abstract
Concurrent alcohol and opioid withdrawal syndrome is a common and challenging clinical scenario with little published evidence or guidance to inform pharmacotherapy strategies. Concurrent use of benzodiazepines and opioid agonists, which are considered first-line agents for management of each withdrawal syndrome independently, is controversial and often avoided in clinical practice. Strategies to provide effective, simultaneous medication treatment of alcohol and opioid withdrawal while optimizing patient safety are demonstrated through 3 patient cases.
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Prince DS, Nash E, Liu K. Alcohol-Associated Liver Disease: Evolving Concepts and Treatments. Drugs 2023; 83:1459-1474. [PMID: 37747685 PMCID: PMC10624727 DOI: 10.1007/s40265-023-01939-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2023] [Indexed: 09/26/2023]
Abstract
Alcohol is a prominent cause of liver disease worldwide with higher prevalence in developed nations. The spectrum of alcohol-associated liver disease (ALD) encompasses a diverse range of clinical entities, from asymptomatic isolated steatosis to decompensated cirrhosis, and in some cases, acute or chronic liver failure. Consequently, it is important for healthcare practitioners to maintain awareness and systematically screen for ALD. The optimal evaluation and management of ALD necessitates a collaborative approach, incorporating a multidisciplinary team and accounting for concurrent medical conditions. A repertoire of therapeutic interventions exists to support patients in achieving alcohol cessation and sustaining remission, with complete abstinence being the ultimate objective. This review explores the existing therapeutic options for ALD acknowledging geographical discrepancies in accessibility. Recent innovations, including the inclusion of alcohol consumption biomarkers into clinical protocols and the expansion of liver transplantation eligibility to encompass severe alcohol-associated hepatitis, are explored.
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Affiliation(s)
- David Stephen Prince
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
- Department of Gastroenterology and Liver, Liverpool Hospital, Sydney, NSW, Australia.
- Liver Injury and Cancer Program, Centenary Institute, Sydney, NSW, Australia.
- The Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.
- Faculty of Medicine and Health, The University of New South Wales, Sydney, NSW, Australia.
| | - Emily Nash
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Ken Liu
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Liver Injury and Cancer Program, Centenary Institute, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Beresford TP, Ronan PJ, Taub J, Learned B, Mi Z, Anderson M. Working Toward a Gold Standard: The Severity of Ethanol Withdrawal Scale (SEWS) Versus the Clinical Institute Withdrawal Assessment Alcohol Scale (CIWA-Ar). Alcohol Alcohol 2023; 58:324-328. [PMID: 36935201 PMCID: PMC10168711 DOI: 10.1093/alcalc/agad016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 02/14/2023] [Accepted: 02/14/2023] [Indexed: 03/21/2023] Open
Abstract
AIM Proving the Severity of Ethanol Withdrawal Scale (SEWS) significantly reduces Alcohol Withdrawal Syndrome (AWS) treatment Time on Medication Protocol (TOMP). METHOD Head-to-head Quality Assurance outcome compared separate cohorts of SEWS or Clinical Institute Withdrawal Assessment Alcohol Scale, Revised (CIWA-Ar) data using Student's t and Wilcoxon tests. RESULTS SEWS-driven treatment (n = 244) reduced TOMP to 2.2 days versus 3.4 days for CIWA-Ar (n = 137); P < 0.0001. CONCLUSION The SEWS is the superior measure of AWS symptoms.
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Affiliation(s)
- Thomas P Beresford
- Laboratory for Clinical and Translational Research in Psychiatry, Rocky Mountain Regional VA Medical Center, Aurora, CO 80045, USA
- Department of Psychiatry, School of Medicine, University of Colorado Denver, Aurora, CO 80045, USA
| | - Patrick J Ronan
- Research Service, Sioux Falls VA Healthcare System, Sioux Falls, SD 57105, USA
- Department of Psychiatry and Division of Basic Biomedical Research, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD 57105 USA
| | - Julie Taub
- Department of Internal Medicine, Denver Health Medical Center, Denver, CO 80204, USA
- Department of Psychiatry, School of Medicine, University of Colorado Denver, Aurora, CO 80045, USA
| | - Brenda Learned
- VHA Office of Community Care - Revenue, VISN 19: Rocky Mountain Network
| | - Zhibao Mi
- Cooperative Studies Program, Perry Point VA Medical Center, Perry Point, MD 21902, USA
- University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Mel Anderson
- Laboratory for Clinical and Translational Research in Psychiatry, Rocky Mountain Regional VA Medical Center, Aurora, CO 80045, USA
- Department of Psychiatry, School of Medicine, University of Colorado Denver, Aurora, CO 80045, USA
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Steel TL, Afshar M, Edwards S, Jolley SE, Timko C, Clark BJ, Douglas IS, Dzierba AL, Gershengorn HB, Gilpin NW, Godwin DW, Hough CL, Maldonado JR, Mehta AB, Nelson LS, Patel MB, Rastegar DA, Stollings JL, Tabakoff B, Tate JA, Wong A, Burnham EL. Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 204:e61-e87. [PMID: 34609257 PMCID: PMC8528516 DOI: 10.1164/rccm.202108-1845st] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Severe alcohol withdrawal syndrome (SAWS) is highly morbid, costly, and common among hospitalized patients, yet minimal evidence exists to guide inpatient management. Research needs in this field are broad, spanning the translational science spectrum. Goals: This research statement aims to describe what is known about SAWS, identify knowledge gaps, and offer recommendations for research in each domain of the Institute of Medicine T0-T4 continuum to advance the care of hospitalized patients who experience SAWS. Methods: Clinicians and researchers with unique and complementary expertise in basic, clinical, and implementation research related to unhealthy alcohol consumption and alcohol withdrawal were invited to participate in a workshop at the American Thoracic Society 2019 International Conference. The committee was subdivided into four groups on the basis of interest and expertise: T0-T1 (basic science research with translation to humans), T2 (research translating to patients), T3 (research translating to clinical practice), and T4 (research translating to communities). A medical librarian conducted a pragmatic literature search to facilitate this work, and committee members reviewed and supplemented the resulting evidence, identifying key knowledge gaps. Results: The committee identified several investigative opportunities to advance the care of patients with SAWS in each domain of the translational science spectrum. Major themes included 1) the need to investigate non-γ-aminobutyric acid pathways for alcohol withdrawal syndrome treatment; 2) harnessing retrospective and electronic health record data to identify risk factors and create objective severity scoring systems, particularly for acutely ill patients with SAWS; 3) the need for more robust comparative-effectiveness data to identify optimal SAWS treatment strategies; and 4) recommendations to accelerate implementation of effective treatments into practice. Conclusions: The dearth of evidence supporting management decisions for hospitalized patients with SAWS, many of whom require critical care, represents both a call to action and an opportunity for the American Thoracic Society and larger scientific communities to improve care for a vulnerable patient population. This report highlights basic, clinical, and implementation research that diverse experts agree will have the greatest impact on improving care for hospitalized patients with SAWS.
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Levine AR, Thanikonda V, Mueller J, Naut ER. Front-loaded diazepam versus lorazepam for treatment of alcohol withdrawal agitated delirium. Am J Emerg Med 2020; 44:415-418. [PMID: 32402500 DOI: 10.1016/j.ajem.2020.04.095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/23/2020] [Accepted: 04/25/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Front-loaded diazepam is used to rapidly control agitation in patients with severe alcohol withdrawal syndrome (AWS). Our institution began using front-loaded lorazepam in August 2017 secondary to a nation-wide shortage of intravenous (IV) diazepam. Currently, there are no studies comparing lorazepam to diazepam for frontloading in severe AWS. METHOD Retrospective cohort study of all adults presenting to the emergency department with a diagnosis of AWS and prescribed the institution's alcohol withdrawal agitated delirium protocol 8 months pre and post shortage of IV diazepam were eligible inclusion for the study. Of these, 106 patients were front-loaded with diazepam and 70 patients were front-loaded with lorazepam. RESULTS There was no difference in the mean change in Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised scores 24 h pre and post front-loading in the two groups (-13.9 ± -8.08 vs. -13.1 ± -8.91, p = 0.534). Patients who received front-loaded lorazepam had an increased incidence of ICU-delirium (positive for the Confusion Assessment Method in the ICU: 75% with lorazepam vs. 52.6% with diazepam, p = 0.009) and a higher risk of over-sedation, but this did not reach statistical significance (Richmond Agitation-Sedation Scale score < -1: 32.1% with lorazepam vs. 18.2% with diazepam, p = 0.063). CONCLUSION Front-loaded lorazepam was similar to front-loaded diazepam in controlling AWS symptoms. Lorazepam's delayed onset of action should be considered when determining how quickly repeat doses are administered to avoid the potential for adverse drug events.
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Affiliation(s)
- Alexander R Levine
- Department of Pharmacy Practice, University of Saint Joseph School of Pharmacy & Physician Assistant Studies, Hartford, Connecticut, United States of America; Clinical Pharmacist, Department of Pharmacy, Saint Francis Hospital and Medical Center, Hartford, Connecticut, United States of America.
| | | | - Jane Mueller
- Clinical Pharmacist, Department of Pharmacy, Saint Francis Hospital and Medical Center, Hartford, Connecticut, United States of America
| | - Edgar R Naut
- UConn Health, Farmington, Connecticut, United States of America; Department of Medicine, Hartford, Connecticut, United States of America
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Holleck JL, Merchant N, Gunderson CG. Symptom-Triggered Therapy for Alcohol Withdrawal Syndrome: a Systematic Review and Meta-analysis of Randomized Controlled Trials. J Gen Intern Med 2019; 34:1018-1024. [PMID: 30937668 PMCID: PMC6544709 DOI: 10.1007/s11606-019-04899-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/20/2018] [Accepted: 02/05/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Benzodiazepines are the standard medication class for treating alcohol withdrawal. Guidelines recommend dosing based on objectively measured symptoms (symptom-triggered therapy) rather than fixed dose regimens. However, the superiority of symptom-triggered therapy has been questioned, and concerns have been raised about its inappropriate use and safety. We aimed to assess whether symptom-triggered therapy is superior to fixed dose schedules in terms of mortality, delirium, seizures, total benzodiazepine dose, and duration of therapy. METHODS A systematic literature search using Medline, Embase, and the Cochrane Registry through February 2018 was conducted for randomized controlled trials of patients with alcohol withdrawal syndrome comparing fixed dose benzodiazepine schedules to symptom-triggered therapy. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Outcomes were pooled using random effects meta-analysis. Heterogeneity was estimated using the I2 statistic. Strength of evidence was assessed using methods outlined by the Agency for Healthcare Research and Quality. RESULTS Six studies involving 664 patients were included. There were no deaths and only one seizure in each group. Four studies reported delirium, which occurred in 4 out of 164 patients randomized to symptom-triggered therapy compared to 6 out of 164 randomized to fixed dose therapy (odds ratio, 0.64 [95% CI, 0.17-2.47]). Three studies reported duration of therapy, which was 60.4 h less with symptom-triggered therapy (95% CI, 39.7-81.1 h; p < 0.001). Six studies reported total benzodiazepine dosage, which was 10.5 mg in lorazepam-equivalent dosing less with symptom-triggered therapy (95% CI, 7.1-13.9 mg; p = 0.011). DISCUSSION Moderate strength evidence suggests that symptom-triggered therapy improved duration of therapy and total benzodiazepine dose in specialized detoxification settings of low-risk patients but the applicability of this evidence in general hospital settings is low. There was insufficient evidence for any conclusions about symptom-triggered therapy for the major outcomes of mortality, seizure, and delirium in any setting. PROSPERO REGISTRATION CRD42017073426.
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Affiliation(s)
- Jürgen L Holleck
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA. .,Department of Medicine, West Haven VA Hospital, Veterans Affairs Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT, 06516, USA.
| | - Naseema Merchant
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.,Department of Medicine, West Haven VA Hospital, Veterans Affairs Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT, 06516, USA
| | - Craig G Gunderson
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.,Department of Medicine, West Haven VA Hospital, Veterans Affairs Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT, 06516, USA
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Evaluation of a Symptom-triggered Protocol for Alcohol Withdrawal for Use in the Emergency Department, General Medical Wards, and Intensive Care Unit. J Psychiatr Pract 2019; 25:63-70. [PMID: 30633735 DOI: 10.1097/pra.0000000000000354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Alcohol withdrawal is common in hospitalized patients and symptom-triggered guidelines have been shown to reduce treatment duration, length of stay, and need for mechanical ventilation. OBJECTIVES To assess the feasibility of incorporating symptom-triggered alcohol withdrawal guidelines early in the hospital course and to evaluate outcomes of patients before and after implementation of the guidelines. METHODS This was a retrospective pre-post study of adult patients admitted from the emergency department to an urban, academic, tertiary care center. Subjects in the preguideline (PRE) group were given benzodiazepines in a nonprotocolized manner at the discretion of the treating physician, whereas subjects in the postguideline (POST) group were treated according to the alcohol withdrawal guidelines with treatment beginning in the emergency department. RESULTS The PRE group involved 113 admissions for severe alcohol withdrawal and the POST group involved 103 admissions for severe alcohol withdrawal. The median benzodiazepine dose per day, in milligrams of chlordiazepoxide, was higher in the POST group (100 mg in the PRE group vs. 141 mg in the POST group; P<0.02). A higher percentage of patients in the POST group were admitted to the intensive care unit (4.4% in the PRE group vs. 12.6% in the POST group; P=0.05); however, more patients in the PRE group than in the POST group received continuous intravenous sedation and mechanical ventilation, although the difference was not statistically significant (P=0.37 for both variables). There was no difference between the 2 groups in length of stay in the intensive care unit or hospital or discharge disposition. CONCLUSIONS Incorporating symptom-triggered guidelines for alcohol withdrawal early in the hospital course at a large medical center is feasible. This approach may result in increased benzodiazepine use, but it seems that it is safe and does not result in adverse outcomes.
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Guirguis E, Richardson J, Kuhn T, Fahmy A. Treatment of Severe Alcohol Withdrawal: A Focus on Adjunctive Agents. J Pharm Technol 2017; 33:204-212. [PMID: 34860943 DOI: 10.1177/8755122517714491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Objective:To review adjunctive treatment options for severe alcohol withdrawal. Data Sources: The search strategy included a search of Ovid MEDLINE using keywords alcohol withdrawal, severe alcohol withdrawal, AWS, delirium tremens, delirium, dexmedetomidine, propofol, anticonvulsants, clonidine, and phenobarbital and included articles dated from January 1990 to March 2017. Study Selection and Data Extraction: All English-language clinical trials and case reports assessing the efficacy of adjunctive agents in severe alcohol withdrawal were evaluated. Data Synthesis: Although first-line pharmacotherapy for alcohol withdrawal continues to be benzodiazepines, literature does not clearly define adjunctive treatment options for severe alcohol withdrawal. During severe alcohol withdrawal patients may become unable to tolerate or may become unresponsive to high-dose benzodiazepines. Large doses of benzodiazepines may also result in oversedation, respiratory insufficiency, and worsening delirium. Conclusions: Phenobarbital and dexmedetomidine are both viable adjunctive treatment options for severe alcohol withdrawal. Current evidence has shown these agents decrease the dose requirements of benzodiazepines with limited incidence of adverse reactions. Propofol may also be a viable option in mechanically ventilated patients, but its lack of clear safety and efficacy advantages over current treatment options may limit its use in practice. Clonidine, oral anticonvulsants, and ketamine require further controlled clinical trials to clearly define their role in the treatment of severe alcohol withdrawal.
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Affiliation(s)
| | | | - Tara Kuhn
- Palm Beach Atlantic University, West Palm Beach, FL, USA
| | - Ashley Fahmy
- Palm Beach Atlantic University, West Palm Beach, FL, USA
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Beresford T, Anderson M, Pitts B, Learned B, Thumm B, Maravilla F, Emrick C, Taub J. The Severity of Ethanol Withdrawal Scale in Scale-Driven Alcohol Withdrawal Treatment: A Quality Assurance Study. ALCOHOLISM TREATMENT QUARTERLY 2017. [DOI: 10.1080/07347324.2017.1322418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Thomas Beresford
- Laboratory for Clinical and Translational Research in Psychiatry, Department of Veterans Affairs, Denver, Colorado, USA
- Psychiatry Service Department of Veterans Affairs, Department of Psychiatry, Denver, Colorado, USA
| | - Mel Anderson
- Medicine Service Department of Veterans Affairs, Denver, Colorado, USA
- Department of Medicine, School of Medicine, University of Colorado Denver, Denver, Colorado, USA
| | - Brian Pitts
- Laboratory for Clinical and Translational Research in Psychiatry, Department of Veterans Affairs, Denver, Colorado, USA
| | - Brenda Learned
- Quality Assurance Program, Department of Veterans Affairs, Denver, Colorado, USA
| | - Brie Thumm
- Laboratory for Clinical and Translational Research in Psychiatry, Department of Veterans Affairs, Denver, Colorado, USA
| | - Francisco Maravilla
- Laboratory for Clinical and Translational Research in Psychiatry, Department of Veterans Affairs, Denver, Colorado, USA
| | - Chad Emrick
- Laboratory for Clinical and Translational Research in Psychiatry, Department of Veterans Affairs, Denver, Colorado, USA
| | - Julie Taub
- Department of Medicine, School of Medicine, University of Colorado Denver, Denver, Colorado, USA
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA
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Impact of an Alcohol Withdrawal Treatment Pathway on Hospital Length of Stay: A Retrospective Observational Study Comparing Pre and Post Pathway Implementation. J Psychiatr Pract 2017; 23:233-241. [PMID: 28492463 DOI: 10.1097/pra.0000000000000229] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine if the implementation of a hospital-specific alcohol withdrawal treatment pathway used in a medical-surgical patient population decreased hospital length of stay (LOS) compared with the standard of care. METHODS This retrospective observational study, conducted in a large academic tertiary care hospital, involved 582 subjects who met criteria for study inclusion, with 275 subjects in the 2010 cohort and 307 in the 2012 cohort. The Alcohol Withdrawal Project Team was formed with the goal of creating a standardized approach to the recognition and treatment of alcohol withdrawal at Duke University Hospital. The group created a computerized physician order entry alcohol withdrawal treatment pathway with 4 possible treatment paths chosen on the basis of current withdrawal symptoms, vital signs, and alcohol withdrawal history. The 4 treatment paths are 1 prophylaxis; 2 mild-to-moderate withdrawal; 3 moderate-to-severe withdrawal, and 4 severe withdrawal/alcohol withdrawal delirium. Each treatment path corresponds to a different lorazepam dose and dose schedule and symptom assessment. This pathway was implemented in the hospital at the end of 2011. RESULTS Using a Cox proportional hazards model and adjusting for covariates, there was a 1 day [95% confidence interval (CI), 1-2 d] reduction in median hospital LOS between the 2010 and 2012 cohorts, 5 versus 4 days, respectively. The average ratio in hospital LOS between the 2 cohorts was 1.25 (95% CI, 1.25-1.67). The CI was estimated by bootstrapping and indicated a significantly longer LOS in the 2010 cohort compared with the 2012 cohort. Nonsignificant changes were found in the proportion of subjects admitted to the intensive care unit (24% in 2010 vs. 29.3% in 2012), LOS in the intensive care unit (7.1±8 d in 2010 vs. 5.6±6.9 d in 2012), and proportion of patients discharged with a diagnosis of delirium tremens (17.8% in 2010 vs. 15.3% in 2012). CONCLUSIONS This study demonstrates the successful implementation of an alcohol withdrawal treatment pathway in a medical-surgical population hospitalized in a large tertiary care facility with significant impact on hospital LOS.
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Eberly ME, Lockwood AG, Lockwood S, Davis KW. Outcomes After Implementation of an Alcohol Withdrawal Protocol at a Single Institution. Hosp Pharm 2016; 51:752-758. [PMID: 27803505 DOI: 10.1310/hpj5109-752] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background: There are varying dosing strategies for the administration of benzodiazepines in the setting of alcohol withdrawal. In October 2014, a symptom-based alcohol withdrawal protocol (AWP) using the Clinical Institute Withdrawal Assessment of Alcohol, Revised (CIWA-Ar) scale was implemented at one institution. Objective: To evaluate the safety and efficacy of the AWP. Methods: Retrospective chart review was completed, including patients receiving at least one dose of diazepam for alcohol withdrawal pre- and post-protocol. The primary outcome of this study was the average daily and cumulative dose of diazepam during hospital stay. Secondary outcomes included length of stay and occurrence of seizures or delirium tremens. Results: The average daily dose and the average cumulative dose of diazepam were significantly lower in the post-protocol group (5.4 vs 12.1 mg, p < .001; 35.0 vs 77.6 mg, p < .001, respectively). Length of stay was similar between groups (6.5 vs 6.4 days, p = .91), however, duration of benzodiazepine use was decreased in the post-protocol group (2.2 vs 4.7 days, p < .001). Despite using reduced doses of benzodiazepines, there was no increase in adverse events. Conclusions: The implementation of a symptom-based AWP using the CIWA-Ar scale was associated with a reduced average daily and cumulative dose of diazepam without any apparent safety issues.
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Dixit D, Endicott J, Burry L, Ramos L, Yeung SYA, Devabhakthuni S, Chan C, Tobia A, Bulloch MN. Management of Acute Alcohol Withdrawal Syndrome in Critically Ill Patients. Pharmacotherapy 2016; 36:797-822. [DOI: 10.1002/phar.1770] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Deepali Dixit
- Ernest Mario School of Pharmacy; Rutgers, The State University of New Jersey; Piscataway New Jersey
- Critical Care; Robert Wood Johnson University Hospital; New Brunswick New Jersey
| | | | - Lisa Burry
- Mt. Sinai Hospital; University of Toronto; Toronto Ontario Canada
| | - Liz Ramos
- New York-Presbyterian Weill Cornell Medical Center; New York New York
| | | | | | - Claire Chan
- Yale-New Haven Hospital; New Haven Connecticut
| | - Anthony Tobia
- Division of Psychiatry; Rutgers Robert Wood Johnson Medical School; New Brunswick New Jersey
| | - Marilyn N. Bulloch
- Harrison School of Pharmacy; Auburn University; Auburn Alabama
- Department of Internal Medicine; College of Community Health Sciences; University of Alabama; Tuscaloosa Alabama
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Bacon O, Robert S, VandenBerg A. Evaluating nursing satisfaction and utilization of the Clinical Institute Withdrawal Assessment for Alcohol, revised version (CIWA-Ar). Ment Health Clin 2016; 6:114-119. [PMID: 29955457 PMCID: PMC6007649 DOI: 10.9740/mhc.2016.05.114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction The Clinical Institute Withdrawal Assessment for Alcohol, revised version (CIWA-Ar), developed and validated for research, is used in our inpatient academic medical center. We sought to assess nursing satisfaction with the scale itself, training for using the scale, and nursing staff use of the CIWA-Ar. Methods A retrospective chart review included all patients with an order for CIWA-Ar between August 1, 2014, and September 30, 2014. Data collected included demographics, admitting diagnosis, vital signs, admission blood alcohol level, lorazepam total daily dose, and CIWA-Ar scores. Nursing staff was sent an anonymous, 26-question survey in January 2015. The survey collected demographics, training history, and recommendations for modifications to the CIWA-Ar. Results During the 2-month period, 274 patients had orders for CIWA-Ar, with 113 receiving at least one dose of lorazepam. Lorazepam was not given to 21% of patients when they scored >8 on the CIWA-Ar, whereas 71% of patients received a dose of lorazepam when they had a CIWA score <8. The survey was sent to 2011 clinical nurses, with 284 responses received (14% response rate). Only 36% of responding nurses felt adequately trained to administer the CIWA-Ar. Most nurses preferred on-the-job and online training methods. Discussion Nursing use of the CIWA-Ar could be optimized at this institution. Fewer than half of respondents reported feeling adequately training to administer the CIWA-Ar. Results will be used to improve training for nursing staff regarding scoring of the CIWA-Ar and administering lorazepam to treat alcohol withdrawal syndrome.
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Affiliation(s)
- Opal Bacon
- PGY-2 Psychiatric Pharmacy Resident, Medical University of South Carolina (MUSC) Medical Center, Charleston, South Carolina,
| | - Sophie Robert
- Clinical Pharmacy Specialist, MUSC Medical Center, Charleston, South Carolina
| | - Amy VandenBerg
- Clinical Pharmacy Specialist, MUSC Medical Center, Charleston, South Carolina
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Puscas M, Hasoon M, Eechevarria C, Cooper T, Tamura L, Chebbo A, W. Carlson R. Severe alcohol withdrawal syndrome: Evolution of care and impact of adjunctive therapy on course and complications of 171 intensive care unit patients. J Addict Dis 2016; 35:218-225. [DOI: 10.1080/10550887.2016.1164431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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15
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Alkoholentzugsdelir und akute Komplikationen. Notf Rett Med 2016. [DOI: 10.1007/s10049-015-0108-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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16
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Factor analysis and correlation between CIWA-Ar protocol and biochemical-hematic profile in patients with alcohol withdrawal syndrome. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2015. [DOI: 10.1016/j.hgmx.2015.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Shu JE, Lin A, Chang G. Alcohol Withdrawal Treatment in the Medically Hospitalized Patient: A Pilot Study Assessing Predictors for Medical or Psychiatric Complications. PSYCHOSOMATICS 2015; 56:547-55. [DOI: 10.1016/j.psym.2014.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 11/28/2014] [Accepted: 12/01/2014] [Indexed: 10/24/2022]
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Mirijello A, D’Angelo C, Ferrulli A, Vassallo G, Antonelli M, Caputo F, Leggio L, Gasbarrini A, Addolorato G. Identification and management of alcohol withdrawal syndrome. Drugs 2015; 75:353-65. [PMID: 25666543 PMCID: PMC4978420 DOI: 10.1007/s40265-015-0358-1] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Antonio Mirijello
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Cristina D’Angelo
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Anna Ferrulli
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Gabriele Vassallo
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Mariangela Antonelli
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Fabio Caputo
- Department of Internal Medicine, SS Annunziata Hospital, Cento, Ferrara, Italy
- Department of Clinical Medicine, “G. Fontana” Centre for the Study and Multidisciplinary Treatment of Alcohol Addiction, University of Bologna, Bologna, Italy
| | - Lorenzo Leggio
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, Laboratory of Clinical and Translational Studies, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA
- Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD, USA
- Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, Brown University, Providence, RI, USA
| | - Antonio Gasbarrini
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Giovanni Addolorato
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
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Affiliation(s)
- Lewis S Nelson
- New York University School of Medicine, New York, NY, USA,
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20
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Using dexmedetomidine as adjunctive therapy for patients with severe alcohol withdrawal syndrome: another piece of the puzzle. Crit Care Med 2014; 42:1298-9. [PMID: 24736345 DOI: 10.1097/ccm.0000000000000173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Mainerova B, Prasko J, Latalova K, Axmann K, Cerna M, Horacek R, Bradacova R. Alcohol withdrawal delirium - diagnosis, course and treatment. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2013; 159:44-52. [PMID: 24399242 DOI: 10.5507/bp.2013.089] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 11/21/2013] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Delirium tremens represents the most severe complication of alcohol withdrawal syndrome and, in its complications, significantly increases the morbidity and mortality of patients. Alcohol withdrawal delirium is characterized by features of alcohol withdrawal itself (tremor, sweating, hypertension, tachycardia etc.) together with general delirious symptoms such as clouded consciousness, disorientation, disturbed circadian rhythms, thought processe and sensory disturbances, all of them fluctuating in time. The treatment combines a supportive and symptomatic approach. Benzodiazepines in supramaximal doses are usually used as drugs of choice but in some countries such as the Czech Republic or Germany, clomethiazole is frequently used as well. METHOD A computer search of the all the literature published between 1966 and December 2012 was accomplished on MEDLINE and Web of Science with the key words "delirium tremens", "alcohol withdrawal", "treatment" and "pharmacotherapy". There were no language or time limits applied. CONCLUSIONS When not early recognized and treated adequately, delirium tremens may result in death due to malignant arrhythmia, respiratory arrest, sepsis, severe electrolyte disturbance or prolonged seizures and subsequent trauma. Owing to these possible fatalities and other severe unexpected complications, delirium tremens should be managed at an ICU or wards ensuring vital signs monitoring. In symptomatic treatment, high doses of benzodiazepines, especially lorazepam, diazepam and oxazepam are considered the gold standard drugs. Supportive therapy is also of great importance.
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Affiliation(s)
- Barbora Mainerova
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
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Stehman CR, Mycyk MB. A rational approach to the treatment of alcohol withdrawal in the ED. Am J Emerg Med 2013; 31:734-42. [PMID: 23399338 DOI: 10.1016/j.ajem.2012.12.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 12/17/2012] [Accepted: 12/29/2012] [Indexed: 01/22/2023] Open
Abstract
Approximately 7% of the US population abuses or is dependent on alcohol. Patients with alcohol disorders often seek medical attention in Emergency Departments (EDs) for complications directly related to alcohol use or due to other medical issues associated with alcohol use. Because of increasing lengths of stay in EDs, alcohol-dependent patients are at high risk of developing alcohol withdrawal syndrome (AWS) during their ED visit. This article reviews the physiology of alcohol withdrawal as well as the symptoms of this potentially deadly illness for the practicing emergency physician (EP). We provide evidence-based guidelines for the appropriate ED treatment of moderate to severe AWS, including pharmacologic interventions, adjunctive therapies, and disposition of these patients.
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Affiliation(s)
- Christine R Stehman
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
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