Clinical management of alcohol withdrawal: A systematic review

Development of clinical prediction model to guide the use of CT head scans for non-traumatic Thai patient with seizure: A cross-sectional study

The aim of this study was to develop clinical predictor tools for guiding the use of computed tomography (CT) head scans in non-traumatic Thai patients presented with seizure. A prediction model using a retrospective cross-sectional design was conducted. We recruited adult patients (aged ≥ 18 years) who had been diagnosed with seizures by their physicians and had undergone CT head scans for further investigation. Positive CT head defined as the presence of any new lesion that related to the patient's presented seizure officially reported by radiologist. A total of 9 candidate predictors were preselected. The prediction model was developed using a full multivariable logistic regression with backward stepwise elimination. We evaluated the model's predictive performance in terms of its discriminative ability and calibration via AuROC and calibration plot. The application was then constructed based on final model. A total of 362 patients were included into the analysis which comprising of 71 patients with positive CT head findings and 291 patients with normal results. Six final predictors were identified including: Glasgow coma scale, the presence of focal neurological deficit, history of malignancy, history of CVA, Epilepsy, and the presence of alcohol withdrawal symptom. In terms of discriminative ability, the final model demonstrated excellent performance (AuROC of 0.82 (95% CI: 0.76-0.87)). The calibration plot illustrated a good agreement between observed and predicted risks. This prediction model offers a reliable tool for effectively reduce unnecessary use and instill confidence in supporting physicians in determining the need for CT head scans in non-traumatic patients with seizures.

Synaptic Mechanisms of Ethanol Tolerance and Neuroplasticity: Insights from Invertebrate Models

Alcohol tolerance is a neuroadaptive response that leads to a reduction in the effects of alcohol caused by previous exposure. Tolerance plays a critical role in the development of alcohol use disorder (AUD) because it leads to the escalation of drinking and dependence. Understanding the molecular mechanisms underlying alcohol tolerance is therefore important for the development of effective therapeutics and for understanding addiction in general. This review explores the molecular basis of alcohol tolerance in invertebrate models, Drosophila and C. elegans, focusing on synaptic transmission. Both organisms exhibit biphasic responses to ethanol and develop tolerance similar to that of mammals. Furthermore, the availability of several genetic tools makes them a great candidate to study the molecular basis of ethanol response. Studies in invertebrate models show that tolerance involves conserved changes in the neurotransmitter systems, ion channels, and synaptic proteins. These neuroadaptive changes lead to a change in neuronal excitability, most likely to compensate for the enhanced inhibition by ethanol.

Substitution therapy for patients with alcohol dependence: Mechanisms of action and efficacy

New approaches for the treatment of alcohol dependence (AD) may improve patient outcomes. Substitution maintenance therapy is one of the most effective treatment options for opioid and nicotine use disorders. So far, there has been little attention to substitution therapy for the treatment of AD. Here, we explain the mechanistic foundations of alcohol substitution maintenance therapy. Alcohol has many primary targets in the brain (and other organs) and the physical interaction of ethanol molecules with these specific ethanol-sensitive sites on a variety of ionotropic receptors (e.g. GABA-A, NMDA, and nicotinic acetylcholine (nACh) receptors) and ion channels provides the rationale for substitution. As such, a variety of compounds can interact with those ethanol-sensitive sites and can thus substitute for some of the effects of alcohol. For some of these compounds, alcohol discrimination studies have shown their substitution potential. Accordingly, potential substitution treatments include agonists acting at GABA receptors such as sodium oxybate, baclofen and benzodiazepines, NMDA receptor antagonists such as ketamine and memantine, or nAChRs agonists such as varenicline. All these compounds are already approved for other indications and we present clinical evidence for these drugs in the treatment of alcohol withdrawal syndrome (AWS) and in the long-term treatment of AD, and outline future steps for their acceptance as substitution treatment in AD. Finally, we discuss the substitution approach of managed alcohol programs for the most severely affected homeless populations. Results showed that sodium oxybate is probably the closest to a substitution therapy for AD and is already approved for the treatment of AWS and in the long-term treatment of AD in some countries. In conclusion, we argue that better AD treatment can be provided if substitution maintenance treatments for alcohol are implemented at a similar scale as for opioid and nicotine use disorder.

Comparison of phenobarbital monotherapy to a benzodiazepine-based regimen for management of alcohol withdrawal syndrome in trauma patients

BACKGROUND

Alcohol withdrawal syndrome (AWS) is associated with increased morbidity and mortality in the trauma population. Benzodiazepines (BZDs) are standard of care for AWS; however, given the risk of delirium with BZDs and reports of BZD-refractory withdrawal, phenobarbital (PHB) has emerged as an alternative therapy for AWS. Safety and efficacy studies of PHB for AWS in trauma patients are lacking. Our aim was to compare a BZD versus PHB protocol in the management of AWS in trauma patients.

METHODS

We performed a retrospective cohort study at a level 1 trauma center of patients at risk for AWS managed with either a BZD or a low-dose oral PHB regimen. Patients were excluded if they were taking BZDs or barbiturates before admission, received propofol or dexmedetomidine before initiation of the study drug, presented with delirium tremens or seizures, or died or discharged within 24 hours of presentation. The primary outcome was complicated AWS (seizures or alcohol withdrawal delirium/delirium tremens). Secondary outcomes included uncomplicated AWS; therapy escalation; oversedation; delirium-, intensive care unit-, and ventilator-free days; and length of stay.

RESULTS

A total of 411 patients were identified; 118 received BZD, and 293 received PHB. The odds of developing complicated AWS with PHB versus BZD-based therapy were not statistically significant (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.21-1.39); however, patients receiving PHB were less likely to develop uncomplicated AWS (OR, 0.08; 95% CI, 0.04-0.14) and less likely to require escalation of therapy (OR, 0.45; 95% CI, 0.24-0.84). The PHB group had a length of stay 3.1 days shorter than the BZD group ( p = 0.002). There was no difference in intensive care unit-, ventilator-, or delirium-free days.

CONCLUSION

A PHB-based protocol for the management of AWS is a safe and effective alternative to BZD-based regimens in trauma patients.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Research protocol of the efficacy of probiotics for the treatment of alcohol use disorder among adult males: A comparison with placebo and acceptance and commitment therapy in a randomized controlled trial

BACKGROUND AND AIM

Primarily, this study compares the efficacy of probiotic and acceptance and commitment therapy (ACT) in alleviating the severity of alcohol craving and alcohol use disorder (AUD) among patients who had undergo two weeks of in-patient detoxification. Secondarily, this study compares the efficacy of probiotic and ACT in mitigating the severity of comorbid depression and anxiety symptoms; decreasing serum level of pro-inflammatory cytokines, such as interleukin 1β (IL-1β), interleukin 6 (IL-6), and tumor necrosis factor α (TNF-α); changing the event-related potential in electroencephalogram (EEG) and restoring microbiota flora in the gut of AUD patients.

METHODS AND ANALYSIS

Initially, during Phase I of the study, the serum level of IL-1β, IL-6 and TNF-α; ERP changes in the EEG and fecal microbiota content will be compared between 120 AUD patients and 120 healthy controls. Subsequently in Phase II of the study, 120 AUD patients will be randomized by stratified permuted block randomization into the probiotic, ACT and placebo groups in a 1:1:1 ratio. Participants in the probiotic and placebo groups will be administered one sachet per day of Lactobacillus spp. probiotic and placebo, respectively for 12 weeks. While those in the ACT group will receive one session per week of ACT for 8 weeks. Outcome measures will be administered at four timepoints, such as t0 = baseline assessment prior to intervention, t1 = 8 weeks after intervention began, t2 = 12 weeks after intervention and t3 = 24 weeks after intervention. Primary outcomes are the degrees of alcohol craving, alcohol withdrawal during abstinence and AUD. Secondary outcomes to be assessed are the severity of co-morbid depression and anxiety symptoms; the serum levels of IL-1β, IL-6 and TNF-α; changes in ERP and fecal microbiota content.

TRIAL REGISTRATION NUMBER

NCT05830708 (ClinicalTrials.gov). Registered on April 25, 2023.

Phenobarbital versus benzodiazepines in alcohol withdrawal syndrome

AIM

Phenobarbital, a long-acting barbiturate, presents an alternative to conventional benzodiazepine treatment for alcohol withdrawal syndrome (AWS). Currently, existing research offers only modest guidance on the safety and effectiveness of phenobarbital in managing AWS in hospital settings. The study objective was to assess if a phenobarbital protocol for the treatment of AWS reduces respiratory complications when compared to a more traditionally used benzodiazepine protocol.

METHODS

A retrospective cohort study analyzing adults who received either phenobarbital or benzodiazepine-based treatment for AWS over a 4-year period, 2015-2019, in a community teaching hospital in a large academic medical system.

RESULTS

A total of 147 patient encounters were included (76 phenobarbital and 71 benzodiazepine). Phenobarbital was associated with a significantly decreased risk of respiratory complications, defined by the occurrence of intubation (15/76 phenobarbital [20%] vs. 36/71 benzodiazepine [51%]) and decreased incidence of the requirement of six or greater liters of oxygen when compared with benzodiazepines (10/76 [13%] vs. 28/71 [39%]). There was a significantly higher incidence of pneumonia in benzodiazepine patients (15/76 [20%] vs. 33/71 [47%]). Mode Richmond Agitation Sedation Scale (RASS) scores were more frequently at goal (0 to -1) between 9 and 48 h after the loading dose of study medication for phenobarbital patients. Median hospital and ICU length of stay were significantly shorter for phenobarbital patients when compared with benzodiazepine patients (5 vs. 10 days and 2 vs. 4 days, respectively).

CONCLUSION

Parenteral phenobarbital loading doses with an oral phenobarbital tapered protocol for AWS resulted in decreased risk of respiratory complications when compared to standard treatment with benzodiazepines.

Association Between Opioid Use Disorder and Seizure Incidents Among Alcohol Use Disorder Patients

Many previous studies have discussed an association between alcohol use disorder (AUD) and seizure incidents. There are also case reports of seizures during opioid withdrawals. Therefore, it is possible that AUD patients may have a higher risk of seizures if they also have opioid use disorder (OUD). However, it remains unproven whether AUD patients with a dual diagnosis of OUD have higher seizure incidents, to our knowledge. This study explored seizure incidents among the patients with a dual diagnosis of AUD and OUD as well as seizures among AUD only or OUD only patients. This study utilized de-identified data from 30 777 928 hospital inpatient encounters at 948 healthcare systems over 4 years (9/1/2018-8/31/2022) from the Vizient^® Clinical Database for this study. Applying the International Classification of Diseases 10th Revision (ICD-10) diagnostic codes, AUD (1 953 575), OUD (768 982), and seizure (1 209 471) encounters were retrieved from the database to examine the effects of OUD on seizure incidence among AUD patients. This study also stratified patient encounters for demographic factors such as gender, age, and race, as well as the Vizient-categorized primary payer. Greatest gender differences were identified among AUD followed by OUD, and seizure patient groups. The mean age for seizure incidents was 57.6 years, while that of AUD was 54.7 years, and OUD 48.9 years. The greatest proportion of patients in all 3 groups were White, followed by Black, with Medicare being the most common primary payer in all 3 categories. Seizure incidents were statistically more common (P < .001, chi-square) in patients with a dual diagnosis of AUD and OUD (8.07%) compared to those with AUD only (7.55%). The patients with the dual diagnosis had a higher odd ratio than those with AUD only or OUD only. These findings across more than 900 health systems provide a greater understanding of seizure risks. Consequently, this information may help in triaging AUD and OUD patients in certain higher-risk demographic groups.

Magnesium in the treatment of alcohol withdrawal syndrome: a multicenter randomized controlled trial

OBJECTIVE

Alcohol withdrawal syndrome (AWS) is a frequent and potentially life-threatening condition experienced in alcohol use disorder. Since hypomagnesemia is involved in AWS's severity, we conducted a multicenter double-blind randomized placebo-controlled trial to examine the efficacy of oral magnesium supplementation as an adjuvant therapy of AWS.

MATERIAL AND METHODS

Inpatients were recruited in six different centers if they had a baseline score higher than eight on the Revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). The experimental treatment was magnesium lactate dehydrate, administrated three times per day providing a total of 426.6 mg per day and up to 15 days. The primary endpoint was the significant between-group difference of the CIWA-Ar total score change from baseline to 3 days later. The treatment group and baseline score were introduced as covariables in an analysis of covariance.

RESULTS

A total of 98 inpatients were included {71.4% of men; mean age of 49.1 years [standard deviation (SD): 10.3]}. In the intention-to-treat population, the mean reduction of the CIWA-Ar score in the experimental group between baseline and 3 days later was 10.1 (SD: 5.2), whereas it was 9.2 (SD: 3.9) in the control group. The absolute difference of the adjusted mean in the experimental group compared with the control group was -0.69 (SD: 0.72), which did not correspond to a significant between-group difference (P = 0.34). Per-protocol analysis and sensitivity analyses also supported this result. Supplementary analyses found no significant difference regarding benzodiazepine consumption, magnesium blood concentration, and satisfaction to care.

CONCLUSIONS

The present study does not support the rationale of systematic oral magnesium supplementation in patients with AWS.

Severe Alcohol Withdrawal in an Adolescent Male

Ethanol remains one of the most frequently abused agents by adolescents, exceeding all others except for vaping nicotine, and use is rising. With increased ethanol use comes a greater risk for dependence and potential for alcohol withdrawal syndromes (AWS). Pediatric AWS is extremely rare and poorly characterized in the literature. Pediatric acute care practitioners may have limited exposure to AWS. We report the case of a 16-year-old male with a history of polysubstance abuse who presented with mild AWS and progressed rapidly to delirium tremens. His withdrawal was initially refractory to high dose benzodiazepine therapy but responded well to phenobarbital. This case highlights how rapidly and dangerously AWS can progress if not aggressively treated. Given the rise in adolescent alcohol use and potential for life threatening symptoms, practitioners, especially in acute care specialties such as emergency medicine, critical care, and hospital medicine, would benefit from additional familiarity with AWS diagnoses and management strategies.

[Antipsychotic Treatment of Alcohol Withdrawal Syndrome with Focus on Delirium Tremens: a Systematic Review]

BACKGROUND

Delirium tremens (DT) is a common complication of alcohol withdrawal. Pharmacological treatment of hospitalized patients with DT is important in addiction medicine but also in other medical disciplines where DT can occur as a complication of hospitalization. Patients suffering from DT require treatment with benzodiazepines (short-acting benzodiazepines for elderly patients to reduce accumulation), and in cases of psychotic symptoms, treatment with antipsychotics. Benzodiazepines are a first-line treatment for DT. A specific guideline for the use of antipsychotics has yet to be developed. This review discusses the current guidelines and literature on the antipsychotic treatment options in DT.

AIM

Systematic presentation of relevant antipsychotics for the treatment of DT.

METHODS

A systematic literature search was conducted using Scopus and PubMed. The last search was conducted on May 22nd 2022. Original articles and reviews on antipsychotic treatment in alcohol withdrawal and DT were included in this review. Further, international guidelines were also considered. The review was registered using the PROSPERO database (https://www.crd.york.ac.uk/prospero/); CRD42021264611.

RESULTS

Haloperidol is mainly recommended for use in the intensive care unit. There is little literature on the use of atypical antipsychotics to treat DT. Treatment with antipsychotics always should be combined with benzodiazepines, and physicians should watch out for complications like neuroleptic malignant syndrome, QTc interval prolongation, extrapyramidal symptoms and withdrawal seizures resulting from lowering the threshold for seizures.

CONCLUSION

Antipsychotic treatment should depend on the experience of the physician. Beside haloperidol, no other clear recommendations are available.

Prior Periods of Abstinence Among Adults With an Alcohol Use Disorder: A Qualitative Template Analysis

Abstaining from substance use is a goal of many people with alcohol use disorder (AUD). Understanding patient perspectives of a period of abstinence may assist persons with AUD in achieving this goal. We accessed the electronic health records of adults with AUD entering an emergency department in Baltimore, Maryland, who received a brief peer support intervention for substance use. Data contained open-ended text entered by staff after a patient indicated ever having a sustained period of substance abstinence. Using qualitative template analysis methodology, we identified codes and themes from these open-ended responses from N = 153 adults with AUD. The sample was primarily male (n = 109, 71.2%) and White (n = 98, 64.1%) with an average age of 43.8 years (SD = 11.2). Themes identified included the abstinence length, abstinence reason, relapse, triggers, time of relapse, and treatment. The most common code for abstinence length was “between 1 and 5 years” (n = 55, 35.9%). Other abstinence length codes included “less than 1 year” and “more than 5 years.” Relapse triggers included “family (non-death),” “death of a loved one,” “social,” “economic,” and “treatment-related” reasons. Findings from this study could be used to inform strategies for peer support interventions to assist patients with substance abstinence.

Assessing the revised Clinical Institute Withdrawal for Alcohol Scale use at Stikland Hospital

Background

Alcohol use disorder (AUD) is a major public health concern in South Africa (SA). Abrupt cessation or reduction of alcohol intake in chronic users can result in withdrawal symptoms. Benzodiazepines are the treatment of choice but need to be used cautiously in patients with a lifetime history of substance abuse given their highly addictive potential. Symptom-triggered prescription of benzodiazepines during alcohol withdrawal using the Revised Clinical Institute Withdrawal for Alcohol Scale (CIWA-Ar) has been associated with improved safety and reduced benzodiazepines use.

Aim

To investigate if implementation of the CIWA-Ar during alcohol detoxification impacted the dose of benzodiazepines used and withdrawal-related outcomes.

Setting

Alcohol rehabilitation unit (ARU) at Stikland Psychiatric Hospital.

Methods

A retrospective cohort study of 135 admissions over a six-month period comparing two groups: before (2015) and after (2017) the implementation of the CIWA-Ar.

Results

The study noted no differences in sociodemographic and alcohol-associated variables between the two groups, and there were no recorded complications in either group. The 2017 group had a lower percentage of patients that required benzodiazepines (33.8% vs. 51.4%, p = 0.04) and a lower median total amount of benzodiazepines used during alcohol withdrawal (0 mg vs. 5 mg, p = 0.01).

Conclusions

The CIWA-Ar rating scale was an effective alternative to prescribing benzodiazepines pro re nata and decreased the total dose of benzodiazepines used during alcohol withdrawal.

Contribution

The use of a symptom triggered regime, like the CIWA-Ar rating scale, during withdrawal can be implemented safely in a SA treatment setting for patients with low-risk AUD.

Evaluation of Dexmedetomidine as an Adjunct to Phenobarbital for Alcohol Withdrawal in Critically Ill Patients

INTRODUCTION

Dexmedetomidine (DEX) is commonly used with benzodiazepines for the management of alcohol withdrawal syndrome (AWS), but limited data exist regarding its use with phenobarbital (PHB). This analysis evaluated the utility of DEX in addition to PHB for AWS in adult patients admitted to the intensive care unit (ICU).

METHODS

This was a single-center, retrospective cohort analysis of critically ill adult patients who received PHB plus either DEX or different adjunctive therapies (NO-DEX) for AWS between 2018 and 2021. Patients were excluded if they had underlying altered mental status or seizure disorder unrelated to AWS or received PHB at outside hospitals. Coarsened exact matching (CEM) was performed to match patients on baseline characteristics in a 1:1 ratio. The primary outcome was ICU length of stay (LOS). A multivariate linear regression analysis was performed to assess the effects of DEX on ICU LOS when accounting for confounders. Secondary outcomes included days with delirium and incidence of mechanical ventilation after PHB administration.

RESULTS

Of the 606 encounters evaluated, 197 met criteria for inclusion. After CEM, 56 encounters remained in each group for analysis. The median ICU LOS was 97.2 [50.1:139.5] hours for the DEX group and 47.5 [28.8:88.1] hours for the NO-DEX group (P = .002). The multivariate linear regression analysis showed the use of DEX (P = .008) was independently associated with an increased ICU LOS by 49.8 h. The DEX group had higher rates of total delirium days (208 vs 143 days, P < .001) and a higher incidence of mechanical ventilation after PHB administration (32% vs 9%, P < .001).

CONCLUSION

This analysis suggests the use of adjunctive DEX with PHB for AWS was associated with a prolonged ICU LOS. Additional studies are needed to further understand the role of adjunctive DEX in the treatment of AWS in critically ill patients.

Phenobarbital and Alcohol Withdrawal Syndrome: A Systematic Review and Meta-Analysis

Alcohol withdrawal syndrome (AWS) is a complication frequently encountered among patients who are chronic alcohol abusers. It is considered to have a significant impact on the United States healthcare system. It not only has a toll on the healthcare spending but also contributes to significant morbidity and mortality. Benzodiazepines are considered first line in the treatment of AWS. Since patients with alcohol use disorder have downregulated gamma aminobutyric acid (GABA) receptors, this often leads to benzodiazepine resistance. Phenobarbital is also used in the management of alcohol withdrawal syndrome. Here we present a systematic review and meta-analysis of the efficacy and safety of the drug. We conducted an electronic database search for relevant studies published between the inception of the project and November 20, 2022, in three databases, including Medline/PubMed, Embase, and Cochrane Library. Our study included all original studies with prime focus on the baseline characteristics of patients admitted to the intensive care unit (ICU) for alcohol withdrawal syndrome and management/monitoring protocol implemented for its treatment. The primary outcomes that were the focus of our study consisted of changes in the length of hospital stay, length of ICU stay, and changes in scoring systems (for alcohol withdrawal assessment and monitoring) following the implementation of phenobarbital. The secondary outcomes included complications such as intubation and mortality. Based on our analysis, the mean difference in hospital stay was statistically significant at -2.6 (95% CI, -4.48, -0.72, P=0.007) for phenobarbital compared to the benzodiazepine group. We were unable to comment on the heterogeneity in our meta-analysis due to the standard deviation not being reported in one study. There was no statistically significant difference regarding the length of stay in the intensive care unit compared to the control/comparative arm, with a mean difference of -1.17 (95% CI, -1.17, 0.09, P=0.07), with considerable heterogeneity (I²=77%, P=0.002). Our meta-analysis also investigated the risk of intubation between the phenobarbital and the control/comparative group. There was statistically significant difference in the incidence of intubation, relative risk (RR) 0.52 (95% CI, 0.25, 1.08, P=0.08), with considerable heterogeneity (I²=80%, P=0.0001). Our study concludes that phenobarbital is an effective tool in the management of AWS in an ICU setting. However, various studies have reported contradictory results, and vital information appears to be lacking. Moreover, there is a lack of uniformity in terms of phenobarbital dosing. Drug administration should be adapted according to the severity of the symptoms. Further studies need to be conducted discussing the safety profile and adverse effects of the drug when it comes to the management of alcohol withdrawal syndrome.

Vergleich von Clomethiazol und Oxazepam im Alkoholentzug

Zusammenfassung: Zielsetzung: Vergleich von Clomethiazol mit Oxazepam im Alkoholentzug im Hinblick auf die Inzidenz von Delirien und Krampfanfällen, die Reduktion der Entzugssymptome und die Nebenwirkungen. Methodik: Multizentrische, offene Studie. Zunächst wurden alle Patienten scoregesteuert gemäß der Hamburger Alkoholentzugs-Skala (HAES) mit Oxazepam (n= 202) entzogen, danach mit Clomethiazol (n= 218). Es wurden Patienten mit aktuell schweren Entzügen (mind. 50 mg Oxazepam / 10 Kps. Clomethiazol / 24h) und / oder Komplikationen eingeschlossen. Ergebnisse: In der Oxazepam-Gruppe traten mit 3 gegenüber 1 Delirien und 3 gegenüber 2 Krampfanfällen mehr Komplikationen auf als in den Clomethiazol-gestützten Entzügen (n. s.). Die vegetativen Scorepunkte sanken unter beiden Medikamenten etwa gleich stark. Unter Clomethiazol traten signifikant mehr Nebenwirkungen auf als unter Oxazepam. Schlussfolgerungen: Weder für die Prävention von Delirien und Krampfanfällen noch für die Kupierung der vegetativen Entzugssymptome ließ sich eine eindeutige Überlegenheit eines der beiden Medikamente nachweisen. Allerdings ergaben sich starke Hinweise für ein besseres Nebenwirkungsprofil von Oxazepam. Obwohl nur schwere Entzüge in die Studie eingeschlossen wurden, traten Delire nur bei 1,0 % der Patienten auf, Krampfanfälle bei 1,2 %. Das in der Studie verwendete Entzugskonzept mit der Hamburger Alkoholentzugs-Skala kann daher als eine sehr sichere Methode angesehen werden.

Management of Alcohol Withdrawal Syndrome in Patients with Alcoholic Liver Disease

Alcohol withdrawal syndrome (AWS) is a common condition that is seen in treatment-seeking patients with Alcohol use disorder (AUD) and alcoholic liver disease (ALD). AWS, which typically starts within 4-6 h of the last alcohol use, can range from mild symptoms such as insomnia, tremors, and autonomic hyperactivity to more severe symptoms such as seizures and delirium tremens. Clinical Institute Withdrawal Assessment Scale-Alcohol Revised (CIWA-Ar) is the most commonly used scale to assess AWS in clinical practice. The presence of moderate withdrawal as indicated by a score of more than 8 is an indication for pharmacotherapy. Lorazepam and oxazepam are preferred agents for the management of AWS in the setting of ALD. In severe ALD, benzodiazepines should be used cautiously with monitoring due to the risk of excessive sedation or precipitating hepatic encephalopathy.

Comparative efficacy and safety of pharmacotherapies for alcohol withdrawal: a systematic review and network meta-analysis

BACKGROUND AND AIMS

There have been few head-to-head clinical trials of pharmacotherapies for alcohol withdrawal (AW). We, therefore, aimed to evaluate the comparative performance of pharmacotherapies for AW.

METHODS

Six databases were searched for randomized clinical trials through November 2021. Trials were included after a blinded review by two independent reviewers. Outcomes included incident seizures, delirium tremens, AW severity scores, adverse events, dropouts, dropouts from adverse events, length of hospital stay, use of additional medications, total benzodiazepine requirements, and death. Effect sizes were pooled using frequentist random-effects network meta-analysis models to generate summary ORs and Cohen's d standardized mean differences (SMDs).

RESULTS

Across the 149 trials, there were 10 692 participants (76% male, median 43.5 years old). AW severity spanned mild (n = 32), moderate (n = 51), and severe (n = 66). Fixed-schedule chlormethiazole (OR, 0.16; 95% CI, 0.04-0.65), fixed-schedule diazepam (OR, 0.16; 95% CI, 0.04-0.59), fixed-schedule lorazepam (OR = 0.19; 95% CI, 0.08-0.45), fixed-schedule chlordiazepoxide (OR = 0.21; 95% CI, 0.08-0.53), and divalproex (OR = 0.22; 95% CI, 0.05-0.86) were superior to placebo at reducing incident AW seizures. However, only fixed-schedule diazepam (OR, 0.19; 95% CI, 0.05-0.76) reduced incident delirium tremens. Oxcarbazepine (d = -3.69; 95% CI, -6.21 to -1.17), carbamazepine (d = -2.76; 95% CI, -4.13 to -1.40), fixed-schedule oxazepam (d = -2.55; 95% CI, -4.26 to -0.83), and γ-hydroxybutyrate (d = -1.80; 95% CI, -3.35 to -0.26) improved endpoint Clinical Institute Withdrawal Assessment for Alcohol-Revised scores over placebo. Promazine and carbamazepine were the only agents significantly associated with greater dropouts because of adverse events. The quality of evidence was downgraded because of the substantial risk of bias, heterogeneity, inconsistency, and imprecision.

CONCLUSIONS

Although some pharmacotherapeutic modalities, particularly benzodiazepines, appear to be safe and efficacious for reducing some measures of alcohol withdrawal, methodological issues and a high risk of bias prevent a consistent estimate of their comparative performance.

Off-label use of antidepressants, antipsychotics, and mood-stabilizers in psychiatry

Off-label drug prescribing in psychiatry is increasing. Many psychotropic drugs are approved for psychopathologic syndromes rather than based on international standard diagnostic classification systems which might facilitate the clinical decision for off-label prescriptions. The objective of this study was to analyze the prevalence and category of off-label use of psychotropic drugs. The study was conducted in 10 psychiatric hospitals in Germany over a period of 2 years. Prescription data of all patients were retrospectively analyzed after identification of antidepressants, antipsychotics, and mood-stabilizers, which were classified as off-label according to the German prescribing information and diagnostic classification according to ICD-10. In total, 53,909 patient cases (46% female) with a mean age of 46.8 (SD: 18) years were included in the study. 30.2% of the cases received at least one off-label prescription of a psychotropic drug during hospital stay. Off-label prevalence rates differed markedly between different diagnostic groups (ICD-10 F0/G3: 47%, F1: 33%, F2: 25%, F3: 21%, F4: 27%, F6: 46%, F7: 84%). The most often off-label prescribed drugs were quetiapine and mirtazapine for organic mental disorders (F0/G3), valproate and quetiapine in patients with disorders due to psychoactive substance use (F1), valproate in patients with psychotic disorders (F2), and risperidone and olanzapine in patients with affective disorders (F3). The prevalence rate of psychotropic off-label prescriptions is high if restricted to product description and ICD-10 diagnosis. Therefore, current psychiatric guidelines should drug-specifically issue this problem by defining psychiatric off-label indications based on a clear benefit-risk assessment.

Can the alcohol withdrawal scale be applied to post-operative patients?

BACKGROUNDS

Assessment scales are commonly used to diagnose and treat alcohol withdrawal syndrome (AWS) in acute hospitals, although they have only been validated for use in detoxification facilities. There is a significant overlap between the symptoms and signs of AWS and other clinical presentations, including systemic inflammatory response syndrome (SIRS) and the physiological response to surgery. This may lead to both over-diagnosis and inappropriate treatment of AWS. This study sought to determine the false-positive rate for the commonly used Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) among post-operative patients.

METHODS

This was a prospective study of patients undergoing major abdominal surgery at University Hospital Geelong. Patients were recruited who were NOT at risk of alcohol dependency (using the World Health Organisation Alcohol Use Disorders Identification Test). Patients were assessed for AWS using the CIWA-Ar day one post-operatively with a false positive measured as a CIWA-Ar > 7.

RESULTS

A total of 67 patients were included in the study. There were 31 (46%) men and 36 women. Their median age was 52 years (range 27-85). Thirty-six (52%) of patients underwent elective procedures, and 32 were emergencies. Twelve of the 67 patients (18%) had CIWA-Ar scores >seven.

CONCLUSION

In the early post-operative period, the CIWA-Ar tool over-diagnoses AWS in 18% of patients. These false-positives could lead to delayed treatment of serious underlying conditions. We call for caution in the use of alcohol withdrawal scales in the acute hospital setting.

Regulation of glutamate signaling in the extended amygdala by adolescent alcohol exposure

Adolescence is a critical period for brain development and behavioral maturation, marked by increased risk-taking behavior and the initiation of drug use. There are significant changes in gray matter volume and pruning of synapses along with a shift in excitatory to inhibitory balance which marks the maturation of cognition and decision-making. Because of ongoing brain development, adolescents are particularly sensitive to the detrimental effects of drugs, including alcohol, which can cause long-lasting consequences into adulthood. The extended amygdala is a region critically implicated in withdrawal and negative affect such as anxiety and depression. As negative affective disorders develop during adolescence, the effects of adolescent alcohol exposure on extended amygdala circuitry needs further inquiry. Here we aim to provide a framework to discuss the existing literature on the extended amygdala, the neuroadaptations which result from alcohol use, and the intersection of factors which contribute to the long-lasting effects of this exposure.

Closed-Eye Visual Hallucinations Preceding Severe Alcohol Withdrawal

Few existing cases of closed-eye visual hallucinations have been reported. These rare perceptual disturbances are distinct from open-eye visual hallucinations, as observed in Charles Bonnet syndrome. This case report discusses a 35-year-old male who presented with closed-eye visual hallucinations 24 hours before severe alcohol withdrawal. On initial presentation, the patient denied auditory or visual hallucinations. The day before the onset of severe alcohol withdrawal, the patient reported vivid, colorful, and lifelike visual hallucinations with his eyes closed which disappeared with eyes open. The hallucinations consisted of cartoon characters such as Daffy Duck, a lifelike blond woman with curly hair, and a tree-covered landscape. The patient endorsed awareness that the hallucinations were not real. The next day, the patient became acutely delirious with rapid onset of agitation, space-time disorientation, open-eye visual hallucinations, and emotionally disturbing illusions. The patient was promptly transferred to the intensive care unit (ICU) to manage severe alcohol withdrawal, including administration of intravenous sedation. During follow-up evaluation, the patient retained a clear memory of the closed-eye hallucinations. However, he had no recollection of the ICU course. Several etiologies were considered, including alcohol withdrawal complicated by polysubstance withdrawal and acute hepatitis, which resolved following pharmacological treatment. To the best of our knowledge, this is the first case report of its kind. Additional research is required to elucidate the etiology, mechanism, and clinical implications of closed-eye visual hallucinations.

[Treatment of alcohol withdrawal syndrome]

Alcohol withdrawal arises in result of long-lasting or short, but massive, alcohol abuse, manifests itself with oppressive symptoms and in some cases is complicated by seizures, hallucinosis and delirium tremens that may be life-threatening for patients. The leading neurochemical factors underlying alcohol withdrawal syndrome and its complications are lack of GABA and excessive glutamate activity, which is important for therapy choice. The first-line drugs in the treatment of alcohol withdrawal syndrome and alcoholic delirium are benzodiazepines, which have the maximum pharmacological similarity with ethanol. Other medications, including barbiturates, anticonvulsants, propofol, dexmedetomidine, and antipsychotics, may be used as alternatives to and in addition to benzodiazepines, especially in the case of protracted delirium with therapeutic resistance. Certain prospects in the treatment of alcohol withdrawal syndrome are associated with ethylmethylhydroxypyridine succinate, which is a bit similar to benzodiazepines in its pharmacology.

Characterization of the GHB Withdrawal Syndrome

The gamma-hydroxybutyric acid (GHB) withdrawal syndrome can have a fulminant course, complicated by severe complications such as delirium or seizures. Detoxification by tapering with pharmaceutical GHB is a safe way to manage GHB withdrawal. However, a detailed description of the course of the GHB withdrawal syndrome is currently lacking. This study aimed to (1) describe the course of GHB withdrawal symptoms over time, (2) assess the association between vital signs and withdrawal symptoms, and (3) explore sex differences in GHB withdrawal. In this observational multicenter study, patients with GHB use disorder (n = 285) were tapered off with pharmaceutical GHB. The most reported subjective withdrawal symptoms (SWS) were related to cravings, fatigue, insomnia, sweating and feeling gloomy. The most prevalent objective withdrawal symptoms (OWS) were related to cravings, fatigue, tremors, sweating, and sudden cold/warm feelings. No association between vital signs and SWS/OWS was found. Sex differences were observed in the severity and prevalence of specific withdrawal symptoms. Our results suggest that the GHB withdrawal syndrome under pharmaceutical GHB tapering does not strongly differ from withdrawal syndromes of other sedative drugs. The lack of association between vital signs and other withdrawal symptoms, and the relative stability of vitals over time suggest that vitals are not suitable for withdrawal monitoring. The reported sex differences highlight the importance of a personalized approach in GHB detoxification.

Pharmacotherapies for the Treatment of Alcohol Use Disorders During Pregnancy: Time to Reconsider?

It is generally recommended that medications only be used in pregnancy where the potential harms to both the mother and foetus are outweighed by the potential benefits. Despite the known harms associated with alcohol consumption during pregnancy, the use of medication for the treatment of pregnant women with an alcohol use disorder (AUD) appears to be rare. This is likely due to the lack of available data regarding the safety of these medications in pregnancy. We reviewed the literature and weighed up the harms associated with alcohol use and AUD during pregnancy with the potential benefits of medications for AUD in pregnancy, including acamprosate, naltrexone and disulfiram. There is little published evidence to support the safety of medications for AUD in pregnancy. However, from the research available it is likely that only disulfiram has the potential to cause serious foetal harm. While further research is required, acamprosate and naltrexone do not appear to be associated with substantial risks of congenital malformations or other serious consequences. Given the potential risks associated with alcohol consumption during pregnancy, the use of acamprosate and naltrexone should be considered for the treatment of pregnant women with AUD based on the current evidence base, although more research is warranted.

Adjunctive Phenobarbital for Alcohol Withdrawal Syndrome: A Focused Literature Review

OBJECTIVE

To review the literature describing the use of adjunctive phenobarbital in the treatment of severe alcohol withdrawal syndrome (AWS).

DATA SOURCES

PubMed and EMBASE were searched using the following terms: phenobarbital, adjunct, refractory or treatment resistant, severe or complicated, and alcohol withdrawal delirium or alcohol withdrawal seizures.

STUDY SELECTION AND DATA EXTRACTION

The search was limited to randomized controlled trials (RCTs) and cohort studies published in English.

DATA SYNTHESIS

Seven studies were identified in the emergency department (ED; RCT, n = 1; cohort, n = 2), general medicine ward (cohort, n = 1), and intensive care unit (ICU; cohort, n = 3) settings. For all studies set in the ED and general medicine ward and for 1 ICU study, phenobarbital plus symptom-guided benzodiazepine therapy was compared to symptom-guided benzodiazepine monotherapy. The other 2 ICU studies examined adjunctive phenobarbital before and after implementation of a protocol, meaning patients in both arms could have received phenobarbital. Overall risk of bias across all studies was low to moderate.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

The specific role of adjunctive phenobarbital in AWS is not clear because a majority of studies are retrospective cohorts with varying primary outcomes in different patient care settings.

CONCLUSIONS

In the ED and general medicine ward, phenobarbital demonstrated benzodiazepine-sparing effects. In the ICU, when a protocol guides phenobarbital use, the need for mechanical ventilation may be reduced. Adjunctive phenobarbital was well tolerated. Because of study limitations, it is challenging to provide specific recommendations for adjunctive phenobarbital use in severe AWS.

Determination of the Relationship Between Craving and 4-repeat Allele of DRD4 Gene Polymorphism in the Early Withdrawal Period of Alcohol Use Disorders

OBJECTIVE

Alcohol use disorder (AUD) is a disease with chronic relapses. Risk factors of craving, which is thought to be one of the predictors of relapse, have been studied for a long time. The DRD4 gene is located on chromosome 11p and has a 48-base pair variable number of tandem repeat (VNTR) polymorphisms in the 3rd exon. This study aimed to investigate if a relationship existed between craving and DRD4 VNTR polymorphism and to determine the predictors of craving.

METHODS

A total of 125 patients with AUD were included in the study. The sociodemographic data form, the Michigan Alcoholism Screening Test (MAST), the Obsessive Compulsive Drinking Scale (OCDS), and the Penn Alcohol Craving Scale (PACS) were applied to the patients. Polymerase chain reaction (PCR) was used to determine the DRD4 VNTR variant of all participants in the peripheral blood sample.

RESULTS

In the 4R/4R homozygous group, it was found that the age at first alcohol use was higher and the scores of the OCDS on the seventh day were lower, but this relationship could not be demonstrated in further statistical analyses. In the stepwise linear regression model, the age at first alcohol use, MAST score, duration of AUD, and delirium tremens history were found to be the predictors of craving.

CONCLUSION

DRD4 VNTR polymorphism does not play a role as a predictor of craving. A decrease in age at first alcohol use, an increase in the MAST score, and the presence of delirium tremens were found to be the predictors of craving among the participants of this study.

A multidisciplinary approach to the management of liver disease and alcohol disorders in psychiatric settings (Review)

Society is burdened with the uncontrolled use of alcohol, an ongoing issue, with a substantial associated morbidity and a pressing economical reverberation. It is inevitable that a series of psychiatric patients who display alcohol disorders will be admitted to hospital while also suffering from health conditions, such as liver disease, due to the consumption of alcohol. Managing comorbid patients in a psychiatric facility is a delicate matter that requires a collaborative team. The aim of this systematic paper is to highlight the following: The possibility of treating alcohol use disorder (AUD) and alcohol withdrawal syndrome (AWS) overlapping alcohol liver disease (ALD) within a psychiatric institution, and the importance of a collaborative multidisciplinary team; correctly dosing psychoactive medication when metabolism is affected by ALD; deciding when is it necessary to seek a transfer to a general hospital. Prescribing medication in patients suffering from ALD is still a not a fully documented territory. Protein binding, metabolism, bioavailability, extraction ratios, excretion route, and half-life must be taken into consideration as well as frequently repeating liver panels. Studies suggest that short-acting benzodiazepines are preferred over their alternatives when treating AWS in ALD. All anticonvulsants can be used in patients with decompensated liver disease with caution, although newer generation antiepileptic agents should be first line. Propofol is favored to benzodiazepines or opioids in the case of decompensated cirrhosis. Patients with ALD are likely to be further compromised by the potential hepatocytotoxicity of some pharmacological agents. On that account, having an integrated perspective of the medical case while taking into consideration the underlying illness as well as possible drug interaction is crucial in treating AUD or AWS in a psychiatric institution.

Recidivism in Liver Transplant Recipients for Alcohol-related Liver Disease

Liver transplantation (LT) is the only cure for patients with end-stage liver disease, which offers good long-term survival. The long-term issues after LT affecting survival are cardiovascular disease, chronic kidney disease, de novo malignancies, recurrence of original disease and immunological causes. Alcoholic-related liver disease (ALD) is one of the most common indications for LT worldwide including India. LT for ALD is associated with several unique challenges as compared with other etiologies. Long-term survival after LT in patients with ALD is affected by recidivism. Various studies have shown different predictors of relapse; the main predictors of relapse are pretransplant abstinence, psychiatric comorbidities, and lack of social support. Although several risk scores have been proposed, these scores are not validated. Studies with active involvement of psychiatrist have shown lower relapse rates. The relapse prevention strategy for reducing likelihood and severity of relapse after initial cessation of alcohol uses a combination of pharmacotherapy and cognitive behavioral approach (identifying and addressing high-risk situations for relapse).

Role of Hippocampal Neurogenesis in Alcohol Withdrawal Seizures

Chronic alcohol consumption results in alcohol use disorder (AUD). Interestingly, however, sudden alcohol withdrawal (AW) after chronic alcohol exposure also leads to a devastating series of symptoms, referred to as alcohol withdrawal syndromes. One key feature of AW syndromes is to produce phenotypes that are opposite to AUD. For example, while the brain is characterized by a hypoactive state in the presence of alcohol, AW induces a hyperactive state, which is manifested as seizure expression. In this review, we discuss the idea that hippocampal neurogenesis and neural circuits play a key role in neuroadaptation and establishment of allostatic states in response to alcohol exposure and AW. The intrinsic properties of dentate granule cells (DGCs), and their contribution to the formation of a potent feedback inhibitory loop, endow the dentate gyrus with a "gate" function, which can limit the entry of excessive excitatory signals from the cortex into the hippocampus. We discuss the possibility that alcohol exposure and withdrawal disrupts structural development and circuitry integration of hippocampal newborn neurons, and that this altered neurogenesis impairs the gate function of the hippocampus. Failure of this gate function is expected to alter the ratio of excitatory to inhibitory (E/I) signals in the hippocampus and to induce seizure expression during AW. Recent functional studies have shown that specific activation and inhibition of hippocampal newborn DGCs are both necessary and sufficient for the expression of AW-associated seizures, further supporting the concept that neurogenesis-induced neuroadaptation is a critical target to understand and treat AUD and AW-associated seizures.

[Alcohol withdrawal delirium: What's new for an old disease?]

The management of alcohol withdrawal syndrome is a frequent work in both community medicine and hospital wards. One of the most severe complications of alcohol withdrawal is Delirium Tremens (DT). The purpose of this development is to update knowledge on this complication in terms of diagnosis, evaluation and therapeutic approaches. It also proposes a reflection on the trajectory of care during and after DT.

Haloperidol in palliative care: Indications and risks

Individual response to medication depends on several factors (age, gender, body weight, general clinical condition, genetics, diet, hydration status, comorbidities, co-administered drugs and their mode of administration, smoking, alcohol overuse, environmental factors, e.g. sunlight) that may contribute to adverse drug reactions even at therapeutic doses. Patients in palliative care are at increased risk of these reactions. Unwanted drug effects diminish the quality of life and may lead to a suboptimal dying process. Haloperidol is one of the three most commonly used drugs in palliative care and the most commonly employed typical antipsychotic. It has also been recommended for inclusion into the palliative care emergency kit of home care teams. As such, it is important to be fully conversant with the indications, benefits, and risks of haloperidol, especially in the context of palliative care.

Antipsychotic Drugs in Prevention of Postoperative Delirium-What Is Known in 2020?

Delirium is one of the most frequently reported neuropsychiatric complications in the perioperative period, especially in the population of elderly patients who often suffer from numerous comorbidities undergoing extensive or urgent surgery. It can affect up to 80% of patients who require hospitalization in an intensive care setting postoperatively. Delirium increases mortality, morbidity, length of hospital stay, and cost of treatment. An episode of delirium in the acute phase may lower the general quality of life and increases the risk of cognitive decline long-term. Since pharmacological treatment of delirium is not highly effective, focus of research has shifted towards developing preventive strategies. We aimed to perform a review of the topic based on the most recent literature. We conclude that, based on the available data, it seems impossible to make strong recommendations for using antipsychotic drugs in prophylaxis. Further research should answer the question what, if any, benefit patients receive from the pharmacological prevention of delirium, and which agents should be used.

Lipid profile dysregulation predicts alcohol withdrawal symptom severity in individuals with alcohol use disorder

Alcohol withdrawal syndrome (AWS) is a serious medical condition of high variability in alcohol use disorder (AUD) after drinking cessation. Identification of clinical biomarkers capable of detecting severe AWS is needed. While alcohol consumption and withdrawal are linked with lipid profile dysregulation, the relationship between lipid levels (high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol [LDL-C], and triglycerides) and AWS is unknown. Therefore, this study investigated whether HDL-C, LDL-C, and triglycerides conferred risk for moderate-to-severe AWS symptoms in treatment-seeking individuals (n = 732) admitted to the National Institute on Alcohol Abuse and Alcoholism (NIAAA) alcohol treatment program. Lipid levels were measured upon admission, and the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) assessed AWS severity for generating a three-level AWS typology (none-to-mild, moderate, and severe). Multivariable multinomial logistic regression examined whether lipid levels were associated with risk for moderate-to-severe AWS. We found significant predictive relationships between AWS and HDL-C, LDL-C, and triglycerides. While extremely high HDL-C (≥100 mg/dL) conferred the highest odds for moderate (4.405, 95% CI, 2.572-7.546, p < 0.001) and severe AWS (5.494, 95% CI, 3.541-8.523, p < 0.001), the lowest odds ratios for moderate AWS (0.493, 95% CI, 0.248-0.981, p = 0.044) and severe AWS (0.303, 95% CI, 0.223-0.411, p < 0.001) were associated with high LDL-C (≥160 mg/dL). The present study demonstrates that altered lipid levels, measured upon admission for inpatient AUD treatment, may help to predict which individuals are at risk for medically relevant moderate-to-severe AWS. This suggests that further research into the role of lipid biomarkers in AWS may be beneficial for identifying biologically determined risk profiles in AUD.

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.

Pharmacotherapeutic management of acute alcohol withdrawal syndrome in critically Ill patients

INTRODUCTION

Alcohol withdrawal syndrome is a common and life-threatening condition in patients suffering from alcohol use disorder. Treatment of this syndrome is challenging, especially in patients that are critically ill, either because of withdrawal symptoms or underlying conditions. For the treatment, several pharmacological agents exist, such as benzodiazepines, barbiturates, or dexmedetomidine. Nonetheless, as alcohol withdrawal syndromes can occur in every clinical setting, it is necessary to provide a guideline for clinicians confronted with this syndrome in varying clinical contexts.

AREAS COVERED

The authors provide a systematic review of the literature found in PubMed and Embase following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

EXPERT OPINION

For the treatment of alcohol withdrawal syndrome, medications targeting the GABA system are preferred. Benzodiazepines are regarded as the gold standard. However, as many adjunct therapeutic options exist, it is essential to find symptom-triggered approaches and treatment protocols for the variety of clinical contexts. Apart from that, it is necessary to compare protocols toward clinical variables rather than investigating medications that are in use for the treatment of alcohol withdrawal syndrome.

Encephalopathic Presentation of West Nile Virus Neuroinvasive Disease Confounded by Concomitant History of Acute Alcohol Withdrawal

West Nile neuroinvasive disease (WNND) is a rare and severe manifestation of West Nile virus (WNV) infection that occurs in less than 1% of infected persons. It should be considered in patients who present with fever, neurological symptoms, and a history of recent outdoor activity where mosquitoes were active. This article highlights a case of a 55-year-old man whose history and symptoms of WNND were confounded with an alternate diagnosis, acute alcohol withdrawal. An overview of WNV infections, and important historical clues and objective findings characteristic of neuroinvasive disease, is discussed to increase readers' knowledge of WNV and awareness of when to consider WNND in the diagnostic differential.

Alcohol use disorder and alcohol withdrawal syndrome in Vietnamese hospitalized patients

AIMS

To identify the extent to which patients admitted to a general hospital in Vietnam meet the criteria for risky alcohol drinking, alcohol use disorder (AUD), and alcohol withdrawal syndrome (AWS), describe problems and behavior of alcohol use such as types and quantity of alcohol drinking in a hospitalized population in Vietnam, and investigate the association among age, disease-related factors, and alcohol consumption with AWS.

METHODS

This study was conducted prospectively in 1340 patients admitted to a general hospital. All patients were screened for risky alcohol drinking. Risky alcohol drinkers were assessed by using the Alcohol Use Disorder Identification Test (AUDIT) to identify AUD patients. The diagnosis of AWS was based on criteria defined by Diagnostic and Statistical Manual of Mental Disorders, version 5. The AWS scale was used to quantitate AWS severity level.

RESULTS

Prevalence of risky alcohol drinkers, AUD patients, and AWS patients among hospitalized patients was 15.5%, 13.1%, and 7.3%, respectively. All of the AUD and AWS patients were male. The majority of risky alcohol drinkers, patients with AUD, and patients with AWS were 40-60-year-old men. Almost all patients (98.3%) drank homemade alcohol. Hospitalized patients were more likely to develop AWS if they had liver disease or past experience with AWS.

CONCLUSIONS

AUD and AWS are common in hospitalized patients. Formulating a protocol to identify and care for patients with alcohol-related disorders is urgent.

Alcohol withdrawal syndrome management: Is there anything new?

Patients with alcohol use disorder experience frequently alcohol withdrawal syndrome (AWS), which is a potentially life-threatening condition mainly caused by glutamate overactivity. The aim of therapeutic alcohol withdrawal is the entry into a process of complete and lasting abstinence. Therefore preparing withdrawal is crucial to optimize compliance and efficacy of aftercare. Indeed, performing repeated withdrawal per se without any project of subsequent abstinence may be deleterious, at least because of repeated exposure to glutamate neurotoxicity. Managing AWS mainly consists in anticipating severe withdrawal, decreasing the risk of complications, making this experience as comfortable as possible, preventing from long-term benzodiazepine use, and enhancing motivation to aftercare and long-term abstinence. In particular, there are specific guidelines to choose which benzodiazepine administration approach to adopt (i.e. symptom-triggered, fixed schedule or loading dosage) and which other drugs to deliver (e.g. thiamine, folate, magnesium). Specific precautions should be taken in the elderly.

Investigating the management of alcohol-related presentations in an Australian teaching hospital

INTRODUCTION AND AIMS

Alcohol-related morbidity is estimated to range from 10-38% of the presentations to hospital emergency departments. This study aims to investigate the actual management process for alcohol-related presentations in a teaching hospital in Australia.

DESIGN AND METHODS

Retrospective audit was conducted on the electronic medical records of 210 presentations with a primary or secondary diagnosis of 'alcohol use disorder' at discharge between November 2016 and February 2017. Six key management steps were investigated: identification of alcohol use disorder, documentation, thiamine, alcohol withdrawal assessment, benzodiazepine for alcohol withdrawal and referral to the drug and alcohol consultation liaison service.

RESULTS

Of all the 210 presentations, 77.1% (162) were identified with alcohol use disorder in the initial assessments; 64.3% (135) were documented with alcohol use history, 49.5% (104) were prescribed with thiamine, 48.1% (101) were assessed with the alcohol withdrawal scale, 41% (86) were prescribed with benzodiazepine for alcohol withdrawal and only 38.6% (81) were referred to the drug and alcohol consultation liaison service. Only 8.6% (18) of the initial presentations were directly related to alcohol. These presentations had a higher completion rate in each of the six steps than those (91.4%, 192) not directly related to alcohol. Only 6.2% (13) were formally screened for alcohol use.

DISCUSSION AND CONCLUSIONS

The findings suggest a need to improve the alcohol management practice in the hospital. Routine use of an alcohol screening tool can enable early identification of the alcohol use disorder and to improve the management of this problem in the hospital.

Alcohol Withdrawal: Possible Risk of Latent Scurvy Appearing as Tiredness: A STROBE-Compliant Study

Background

Little is known about the prevalence of vitamin C deficiency in the population of individuals who are withdrawing from alcohol, and about possible consequences of latent scurvy. The aim of this study was to evaluate the prevalence of vitamin C deficiency in patients who were withdrawing from alcohol, its correlation with latent scurvy (mainly tiredness and weakness) and the change in the latter symptoms at 3 months after oral vitamin C supplementation.

Methods

A total of 47 patients (33 males, 14 females) who volunteered to undertake alcohol detoxification were included prospectively between January 2014 and November 2016. Determination of vitamin C blood levels was performed, and selected clinical signs of latent scurvy were recorded in a structured questionnaire. The decrease of tiredness after vitamin C supplementation was also studied 3 months after the inclusion of patients who had no other explanation for their weakness.

Results

About 57.44% of the patients were affected by vitamin C deficiency (< 11.4 mol/L). Less than one-third (29.70%) had a normal plasma vitamin C level. There was a clear correlation between decreased vitamin C levels and the presence of tiredness (P = 0.003) and no correlation between gum inflammation or purpura (P = 0.97 and 0.44 respectively). After 3 months of alcohol withdrawal and vitamin C supplementation, 89% of the patients reported a decrease of tiredness.

Conclusions

Vitamin C deficiency is prevalent in patients undertaking alcohol detoxification. Patients with this vitamin deficiency status often suffer from tiredness, which may be symptoms of latent scurvy. Even if tiredness is a highly nonspecific symptom, presence of fatigue should draw attention and the vitamin C level should be determined. Our preliminary data suggest that vitamin C supplementation, may decrease fatigue and improve patient’s quality of life. This last evolution needs to be confirmed by a double-blind randomized study.

Using a personalized clinical decision support system for bromdihydrochlorphenylbenzodiazepine dosing in patients with anxiety disorders based on the pharmacogenomic markers

INTRODUCTION

Although pharmacogenetic tests provide the information on a genotype and the predicted phenotype, these tests themselves do not provide the interpretation of data for a physician. There are currently approximately two dozen pharmacogenomic clinical decision support systems used in psychiatry. Implementation of clinical decision support systems capable of forming recommendations on drug and dose selection according to the results of pharmacogenetic testing is an urgent task. Fulfillment of this task may allow increasing the efficacy of therapy and decreasing the risk of undesirable side effects.

MATERIALS AND METHODS

The study included 51 male patients (21 in the main group and 30 in the control group) with alcohol withdrawal syndrome. To evaluate the efficacy and safety of therapy, several international psychometric scales and rating scales to measure side effects were used. Genotyping was performed using real-time polymerase chain reaction with allele-specific hybridization. Pharmacogenetic test results were interpreted using free software PGX2 (www.pgx2.com).

RESULTS

Statistically significant differences between the scores derived from all psychometric scales were revealed. For instance, the total score on CIWA-Ar scale by day 3 was 13.5 [11.2; 16.0] for the main group and 18.0 [17.0; 22.0] (p < 0.001) for the control group; by day 5, it was 6.5 [4.2; 8.0] for the main group and 15.0 [14.0; 16.0] (p < 0.001) for the control group. The UKU side effect rating scale (UKU) also revealed a statistically significant difference. The total score on UKU scale by day 3 was 6.0 [5.0; 7.0] for the main group and 7.0 [6.0; 8.0] (p < 0.001) for the control group; by day 5, this difference grew significantly: 5.5 [3.0; 9.0] for the main group and 14.0 [12.0; 19.0] (p < 0.001) for the control group. The groups were representative (there was no difference between the scores at the inclusion of patients).

CONCLUSION

Pharmacogenetic-guided personalization of drug dose in patients with alcohol withdrawal syndrome can reduce the risk of undesirable side effects and pharmacoresistance. It allows recommending the use of pharmacogenomic clinical decision support systems for optimizing drug dosage.

Alcohol Withdrawal Assessment Tool: Validity and Reliability Testing in Acute Care

PURPOSE/AIMS

The purpose of this study was to validate a tool to assess alcohol withdrawal in acute care patients. Study aims included (1) establish content validity, (2) examine criterion-related validity, (3) test interrater reliability, and (4) assess nurse usability.

DESIGN

A psychometric research study was designed to evaluate the Alcohol Withdrawal Assessment Tool.

METHODS

Validation was conducted using an expert panel to determine content validity. The Clinical Institute Withdrawal Assessment for Alcohol-Revised was used as comparison for the criterion related validity. Interrater reliability was determined by having 2 investigators simultaneously complete the assessment on the same patients. Usability was determined using a Likert scale survey.

RESULTS

The average age of participants was 53 years, with a range of 27 to 81 years. Interrater reliability was supported by a κ statistic range of 0.61 to 0.6957, and content validity was supported by a content validity index of 1.0. Criterion-related validity was supported with a Pearson r correlation of 0.665 (P < .000). Of nurses surveyed, all answered agree or strongly agree to the usability survey.

CONCLUSIONS

The assessment tool may be an effective alternative to utilize in the acute care setting. It is easy to use and drives frequency of assessment and appropriate pharmacologic treatment.

Review of thiamine deficiency disorders: Wernicke encephalopathy and Korsakoff psychosis

Wernicke encephalopathy (WE) and Korsakoff psychosis (KP), together termed Wernicke-Korsakoff syndrome (WKS), are distinct yet overlapping neuropsychiatric disorders associated with thiamine deficiency. Thiamine pyrophosphate, the biologically active form of thiamine, is essential for multiple biochemical pathways involved in carbohydrate utilization. Both genetic susceptibilities and acquired deficiencies as a result of alcoholic and non-alcoholic factors are associated with thiamine deficiency or its impaired utilization. WKS is underdiagnosed because of the inconsistent clinical presentation and overlapping of symptoms with other neurological conditions. The identification and individualized treatment of WE based on the etiology is vital to prevent the development of the amnestic state associated with KP in genetically predisposed individuals. Through this review, we bring together the existing data from animal and human models to expound the etiopathogenesis, diagnosis, and therapeutic interventions for WE and KP.

Comparison of propofol with midazolam in endoscopic submucosal dissection for esophageal squamous cell carcinoma: a randomized controlled trial

BACKGROUND

Interruption of sedation due to a poor response to modified neuroleptanalgesia (m-NLA) with midazolam often occurs during endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) because most patients have a history of heavy alcohol intake. Recently, propofol has been used feasibly and safely during endoscopic procedures. The aim of this study was to clarify the efficacy and safety of propofol compared with that of midazolam during ESD for ESCC.

METHODS

This was a single-blind, randomized controlled trial in a single center. Patients with ESCC scheduled for ESD were included in the study. Patients were randomly assigned to one of two groups: the propofol group and the midazolam group. The main outcome was the incidence of discontinuation of the procedure due to a poor response to sedation. Secondary outcomes included risk factors for a poor response to sedation.

RESULTS

Between April 2014 and October 2015, 132 patients (n = 66 per group) who underwent ESD for ESCC were enrolled in this study. The incidence of discontinuation due to a poor response to sedation in the propofol and midazolam groups was 0% (0/66) and 37.9% (25/66), respectively (p < 0.01). Multivariate analyses revealed that use of midazolam [Odds ratio (OR), 7.61; 95% confidence interval (CI), 2.64-21.92; p < 0.01] and age (OR, 0.93; 95% CI, 0.86-0.98; p < 0.01) were risk factors for a poor response to sedation.

CONCLUSIONS

Our study indicates that, compared with midazolam, propofol is a more efficient sedative for m-NLA during ESD for ESCC.

Benzodiazepine maintenance for alcohol dependence: A case series

Alcohol addiction is a chronic relapsing syndrome. Benzodiazepines remain as the mainstay for detoxification, taking care of the acute withdrawal syndrome. There is fear of dependence and abuse of benzodiazepines on prolonged use. Here, we selectively interviewed ten cases who were on longer duration of benzodiazepines to elicit their potential perceived benefits, attitudes, and any adverse effect. Three patients experienced adverse effects. None of them had features of benzodiazepine dependence. We opine that in select cases, benzodiazepine use should persist beyond detox period, and its benefits continue beyond the acute withdrawal phase while monitoring their safety/adverse effects.

Is medical treatment of Alcohol Withdrawal Syndrome a Stag Hunt? Challenges and opportunities in managing risk and uncertainty in addiction cessation

PURPOSE

While the individual and social costs of alcoholism or alcohol use disorder are well established, few are aware that medical problems can arise during detoxification, some of which can be life-threatening. This study determines if sustained treatment for Alcohol Withdrawal Syndrome (AWS) might be based on the strategic choices and expectations of patients and health care providers alike, as well as the risk mitigation options available to them.

DESIGN/APPROACH

AWS was modeled as a Stag Hunt to explain both risk and decision-making in medical treatments for detoxification, since it can deduce a set of equilibrium strategies available to both patient and provider. Modeling was based on a review of juried literature gathered from search engines with the use medical subject heading terms.

MAIN FINDINGS

While there is little evidence that decision-making is shared between patient and physician in AWS treatments, the outcomes of their interactions depend on utility-maximizing choices each makes in anticipation of the other. Payoff-dominant and risk-dominant treatment outcomes are equally likely and equally cost-efficient, as conditioned by the presence (or absence) of mutual trust and assurance in reciprocal transactions.

CONCLUSION/VALUE

Simulation games, such as the Stag Hunt, offer a viable framework to understand patient and provider incentives and health-affecting behaviors during treatments for addiction cessation. If both anticipate indefinitely interacting in the absence of any predetermined or foreseeable final visit, they can maximize future payoffs from mutual cooperation and accountability, which fosters health promotion. However, this study suggests that the effect of cooperation is distinct from the effect of time in AWS and other addiction-cessation programs.

Patient Outcomes Associated With Phenobarbital Use With or Without Benzodiazepines for Alcohol Withdrawal Syndrome: A Systematic Review

Purpose: Benzodiazepines are the drug of choice for alcohol withdrawal syndrome (AWS); however, phenobarbital is an alternative agent used with or without concomitant benzodiazepine therapy. In this systematic review, we evaluate patient outcomes with phenobarbital for AWS. Methods: Medline, Cochrane Library, and Scopus were searched from 1950 through February 2017 for controlled trials and observational studies using ["phenobarbital" or "barbiturate"] and ["alcohol withdrawal" or "delirium tremens."] Risk of bias was assessed using tools recommended by National Heart, Lung, and Blood Institute. Results: From 294 nonduplicative articles, 4 controlled trials and 5 observational studies (n = 720) for AWS of any severity were included. Studies were of good quality (n = 2), fair (n = 4), and poor (n = 3). In 6 studies describing phenobarbital without concomitant benzodiazepine therapy, phenobarbital decreased AWS symptoms (P < .00001) and displayed similar rates of treatment failure versus comparator therapies (38% vs 29%). A study with 2 cohorts showed similar rates of intensive care unit (ICU) admission (phenobarbital: 16% and 9% vs benzodiazepine: 14%) and hospital length of stay (phenobarbital: 5.85 and 5.30 days vs benzodiazepine: 6.64 days). In 4 studies describing phenobarbital with concomitant benzodiazepine therapy, phenobarbital groups had similar ICU admission rates (8% vs 25%), decreased mechanical ventilation (21.9% vs 47.3%), decreased benzodiazepine requirements by 50% to 90%, and similar ICU and hospital lengths of stay and AWS symptom resolution versus comparator groups. Adverse effects with phenobarbital, including dizziness and drowsiness, rarely occurred. Conclusion: Phenobarbital, with or without concomitant benzodiazepines, may provide similar or improved outcomes when compared with alternative therapies, including benzodiazepines alone.