Alcohol withdrawal severity in inbred mouse (Mus musculus) strains

Male mice (Mus musculus) from 15 standard inbred strains were exposed to a nearly constant concentration of ethanol (EtOH) vapor for 72 hr, averaging 1.59 +/- 0.03 mg EtOH/mL blood at withdrawal. EtOH- and air-exposed groups were tested hourly for handling-induced convulsions for 10 hr and at Hours 24 and 25. Strains differed markedly in the severity of withdrawal (after subtraction of control values), and by design these differences were independent of strain differences in EtOH metabolism. Correlation of strain mean withdrawal severity with other responses to EtOH supported previously reported genetic relationships of high EtOH withdrawal with low drinking, high conditioned taste aversion, low tolerance to EtOH-induced hypothermia, and high stimulated activity after low-dose EtOH. Also supported were the positive genetic correlations among EtOH, barbiturate, and benzodiazepine withdrawal. Sensitivity of naive mice to several chemical convulsant-induced seizures was also correlated with EtOH withdrawal.

Placebo-controlled trial of intravenous diphenylhydantoin for short-term treatment of alcohol withdrawal seizures

PURPOSE

Despite conflicting experimental and clinical evidence, diphenylhydantoin continues to be used for the treatment of alcohol withdrawal seizures in emergency departments and alcohol detoxification centers. Our goal was to evaluate the effectiveness of intravenous diphenylhydantoin for prevention of alcohol withdrawal seizures in high-risk patients using a prospective, randomized, double-blind, placebo-controlled study design.

PATIENTS AND METHODS

Ninety alcoholic patients, enrolled within six hours of the initial alcohol-related seizure in a withdrawal episode, were randomly assigned to treatment with intravenous diphenylhydantoin (1,000 mg) or placebo. Seventy-one patients had a history of seizures during prior alcohol withdrawal episodes. Patients with a history of seizures unrelated to alcohol withdrawal were excluded. Drugs known to affect the seizure threshold or demonstrating cross-tolerance with alcohol were withheld. For each patient, the study endpoint was either (1) seizure recurrence or (2) a minimum 12-hour seizure-free observation period after completion of the study drug infusion.

RESULTS

During the postinfusion observation period, six of 45 diphenylhydantoin-treated patients and six of 45 placebo-treated patients experienced at least one recurrent seizure. Equivalent diphenylhydantoin serum levels were measured in patients with and without subsequent seizures. There was no statistically significant difference between the response rates for the two treatments (p greater than 0.05). The 95% confidence interval for the difference in response probabilities was -14.0%, 14%.

CONCLUSION

When administered to non-epileptic patients within six hours of the onset of alcohol withdrawal seizures, intravenous diphenylhydantoin failed to show a significant benefit over placebo in the prevention of subsequent seizures. We suggest that the well-documented risks of intravenous diphenylhydantoin therapy outweigh the potential benefit in the short-term treatment of alcohol withdrawal seizures.

A genotype-controlled analysis of plasma dopamine beta-hydroxylase in healthy and alcoholic subjects: evidence for alcohol-related differences in noradrenergic function

BACKGROUND

Norepinephrine and dopamine mediate important aspects of alcoholism and alcohol withdrawal. Dopamine-beta-hydroxylase (DbetaH) converts dopamine to norepinephrine. A recent study demonstrated a strong association between variance in plasma DbetaH activity and a novel polymorphism (DBH-1021C-->T) at the structural locus (DBH) encoding DbetaH protein.

METHODS

Our study investigated whether the DBH-1021C-->T polymorphism and plasma DbetaH activity were associated with alcoholism or with delirium tremens (DT) during alcohol withdrawal by analyzing 207 German alcoholic and 102 healthy control subjects. We also examined the influence of the polymorphism on enzyme activity.

RESULTS

Mean (+SD) plasma DbetaH activity measured in alcoholic subjects abstinent was significantly lower than that observed in control (27.7 + 16.7 vs. 35.6 + 18.8; p =.01). It did not differ between subjects with DT during withdrawal and subjects with mild withdrawal symptoms. The T allele of the DBH-1021C-->T polymorphism was significantly associated with lower plasma DbetaH activity. None of the alleles or genotypes were associated with alcoholism or DT.

CONCLUSIONS

The data indicate that the alcoholism-related reduction in plasma DbetaH activity is independent of genotype at DBH-1021C-->T and replicate the finding that DBH-1021C-->T is strongly associated with plasma DbetaH activity in a native Western European population.

Does hypokalaemia precede delirium tremens?

Serum-potassium was determined daily in 37 chronic alcoholics when alcohol was withdrawn on admission to hospital. Serum-potassium was normal in all patients at admission but in 26 patients in whom delirium tremens developed a contiuing decrease in serum-potassium led to hypokalaemia, (mean 2.9 mmol/l) when delirium tremens started. At the end of the attack serum-potassium rapidly returned to normal. The change in serum-potassium was not associated with any variation in serum electrolytes or acidbase balance. In the 11 patients in whom delirium tremens did not develop serum-potassium concentration remained unchanged.

Thiamin and thiamin phosphate ester deficiency assessed by high performance liquid chromatography in four clinical cases of Wernicke encephalopathy

The concentrations of thiamin and thiamin phosphate esters were determined by high performance liquid chromatography in four patients with clinical Wernicke encephalopathy. Three were alcohol abusers, and one had prolonged vomiting and anorexia. Thiamin and thiamin monophosphate were assessed in plasma and whole blood (four patients) and in cerebrospinal fluid (two patients) before and during thiamin treatment. Thiamin diphosphate was also assessed in whole blood in the four patients. Before treatment, thiamin monophosphate was significantly decreased in all patients, and thiamin diphosphate in three. A poor increase in thiamin mono- and diphosphate was paralleled by a slow clinical improvement in one patient, while an increase in all thiamin compounds was observed in two patients with a rapid recovery. Thiamin monophosphate was a more sensitive marker of deficiency than thiamin diphosphate and unphosphorylated thiamin.

Regional cerebral blood flow during alcohol withdrawal

Serial bilateral measurements of regional cerebral blood flow (rCBF) by the xenon Xe 133 inhalation method were made during 13 withdrawal periods in 12 male alcoholics with pronounced physical dependence. A significant global reduction of rCBF was found during the first two days of withdrawal. The largest decreases were seen in cases with clouded sensorium and with an extended preceding drinking period. An rCBF distribution with relatively high temporal and low parietal flows during the first two days was coupled to aggravated symptoms. In two men who reported auditory and visual hallucinations during the measurements, elevated rCBF values were found in the temporal, Sylvian, and occipital regions.

Clinical predictors of alcohol withdrawal delirium

Up to now, clinical predictors for the course of the alcohol withdrawal syndrome, especially for the occurrence of a delirium, are lacking. Thus, this study was undertaken to examine whether clinical routine investigations at admission before the withdrawal syndrome can reveal factors indicating a higher risk for the development of a delirium. Our results showed that decreased serum electrolyte concentrations (i.e., chloride and potassium), elevated ALT, and gamma-glutamyltransferase serum levels, as well as ataxia and polyneuropathy at the neurological examination, indicate a higher risk for the development of an alcohol withdrawal delirium.

Increase in glycosylated and nonglycosylated serum ferritin in chronic alcoholism and their evolution during alcohol withdrawal

Increase in serum ferritin, which occurs in 40 to 70% of chronic alcoholics, remains poorly understood. We tested the hypothesis which links hyperferritinemia in chronic alcoholism not only to ferritin release from damaged liver cells, but also to increased ferritin secretion. Fifty-eight chronic alcoholic patients hospitalized for alcohol withdrawal were subdivided into three groups according to liver damage. Their serum levels of ferritin and ferritin bound to concanavalin A (ferritin Con A, which represents glycosylated, i.e., secreted ferritin) were measured serially on days 1, 7, and 11 of withdrawal and compared with a control group. The results were: (1) Total serum ferritin increased in alcoholics. Both free and Con A ferritins increased in equal proportions, the ferritin Con A to total ferritin ratio remaining unchanged. The increase was dependent on liver disease, as both free and Con A ferritins increased significantly with the severity of liver illness. Serum ferritin levels were related to iron status: it correlated with hepatic iron concentration (obtained in 19 patients); however, high ferritin values were not related to the degree of iron overload, which remained low. Finally, there was no correlation between serum ferritin and the average of alcohol consumption. (2) Both free and Con A ferritin decreased by about 40% during alcohol withdrawal. In conclusion, we have demonstrated that (1) total serum ferritin is increased in chronic alcoholism and (2) that this ferritin increase is due in part to an increase in ferritin Con A, proof of the induction of ferritin secretion by alcohol in humans.

Inappropriate vasopressin secretion in severe alcohol withdrawal

Forty-one male alcoholics suffering from alcohol withdrawal syndrome were investigated to assess the relationship between vasopressin (ADH), water homeostasis and alcohol withdrawal. During 10 d, we found a significant decrease in serum vasopressin, from 3.08 +/- 0.61 to 1.71 +/- 0.22 pg/nl. There were no concomitant changes in osmolality, so that a general dysregulatory state of vasopressin secretion during alcohol withdrawal cannot be assumed. Only patients with delirium tremens (8/41) had higher vasopressin levels despite lowered serum osmolalities. These findings support the hypothesis of an inappropriate rebound secretion of vasopressin in severe alcohol withdrawal. Furthermore, they may contribute to the pathogenesis of focal alcoholic brain damage, because rapid and/or profound changes in osmolality are suspected to cause circumscribed cerebral demyelinization.

Blood platelet uptake of serotonin in men alcoholics

Blood platelet uptake of 3H-serotonin (5HT uptake) was determined in a group of inpatient alcoholics who had just undergone detoxication (N = 19) and an age-matched group of nonalcoholic controls (N = 19). Mean 5HT uptake was 18% lower in the alcoholics (p less than .01). A 3-min 5HT uptake of less than 6 pmoles/10(7) platelets identified 58% of the alcoholics, but only 15% of the controls had a 5HT uptake lower than this value. These results support the hypothesis that serotonergic dysfunction may exist in alcoholics.

Dexamethasone suppression test in alcoholism

The hypothalamic-pituitary-adrenal function was investigated in alcoholic patients using the dexamethasone suppression test (DST). Seventy-two patients were studied when they had been abstinent from alcohol for 3 to 6 weeks. Eight patients undergoing detoxification and 79 control subjects were investigated for comparison. Alcoholic patients after a 3- to 6-week abstinence period showed significantly higher prevalence of abnormal DST results (28%) than control subjects (11%). Patients undergoing detoxification showed even a higher prevalence of abnormal DST results (62%). Abnormal DST status was not associated with the presence of depression in these patients but was associated with abnormal liver function. It is supposed that abnormal DST responses in alcoholic patients are not diagnostic of depression but appear to be related to effects of alcohol either on liver metabolism or on the hypothalamic-pituitary-adrenal function or both.

The effect of alcohol withdrawal on serum concentrations of Lp(a), apolipoproteins A-1 and B, and lipids

Moderate alcohol consumption is associated with a decreased risk of coronary artery disease. The mechanism of the putative protective effect of alcohol intake, however, remains elusive. Recent studies suggest that a ratio of apolipoprotein A-I/apolipoprotein B and Lp(a) are better indicators of the risk of atherosclerosis than total cholesterol and high density lipoprotein cholesterol. To assess the effect of alcohol on these analytes, we determined the concentration of Lp(a), apolipoprotein A-I, apolipoprotein B, total cholesterol, and high-density lipoprotein cholesterol, and calculated low-density lipoprotein cholesterol in serum of 12 patients meeting DSM-III-R criteria for alcohol dependence at the time of admission for treatment of alcohol withdrawal (before). The analyses were repeated after 4 weeks of supervised abstinence on a locked research unit (after). With abstinence, there was a significant increase in the concentration of Lp(a), the atherogenic index and the ratio of low-density to high-density lipoprotein cholesterol but a significant decrease in total cholesterol, high-density lipoprotein cholesterol, apolipoprotein A-I, and the apolipoprotein A-I/B ratio. Apolipoprotein B and low-density lipoprotein cholesterol showed no significant changes before and after alcohol abstinence. Thus, decreased Lp(a) and increased high-density lipoprotein cholesterol and apolipoprotein A-I may be factors mediating the putative protective effect of alcohol in coronary artery disease.

Changes in human plasma nerve growth factor level after chronic alcohol consumption and withdrawal

Numerous studies reported in recent years have shown that withdrawal from chronic consumption of drugs induces high levels of anxiety, both in humans and in animal models. In the present study, we demonstrated that withdrawal from chronic consumption of either ethanol or heroin causes a significant increase in plasma nerve growth factor, suggesting that the resulting anxiety condition triggers the release of this molecule. Although the functional significance of this phenomenon needs to be better defined, it is hypothesized that the increased levels of circulating nerve growth factor might be involved in homeostatic adaptive and/or reparative mechanisms.

Plasma homovanillic acid: a significant association with alcoholism is independent of a functional polymorphism of the human catechol-O-methyltransferase gene

The central dopamine system seems to influence addictive disorders. Plasma homovanillic acid (HVA) is an indicator of central dopaminergic activity. In this study the hypothesis that plasma HVA is associated with alcoholism or with delirium tremens (DT) during alcohol withdrawal was tested. A functional genetic polymorphism of the enzyme catechol-O-methyltransferase (COMT) that participates in converting dopamine into its final metabolite HVA was investigated for an association with alcoholism or DT during alcohol withdrawal. In addition, a relation between the functional polymorphism of COMT and plasma HVA concentrations was studied. Plasma HVA concentrations and COMT genotypes were determined in 142 German alcoholics and 101 German healthy controls. Alcoholic patients were examined after a minimum of 3 weeks after cessation of drinking. Mean plasma HVA concentrations were significantly lower in alcoholic patients compared to healthy controls. A group of alcoholics with a history of DT during alcohol withdrawal (n=62) did not differ significantly in plasma HVA concentrations from alcoholics with a history of only mild withdrawal symptoms (n=67). The functional polymorphism of the human COMT gene was neither significantly associated with the diagnosis of alcoholism or DT during alcohol withdrawal nor with plasma HVA concentrations.

Massive benzodiazepine requirements during acute alcohol withdrawal

Severe alcohol withdrawal developed in an abstinent chronic alcoholic man. Massive doses of benzodiazepines (2,335 mg of diazepam intravenously, 21,225 mg of oxazepam orally) achieved only marginal control of delirium and agitation. Analysis of multiple blood samples drawn during and after the withdrawal episode indicated, as expected, very high concentrations of diazepam and metabolites and of oxazepam. There was no evidence of an abnormal pharmacokinetic profile. Benzodiazepine resistance in withdrawing alcoholics probably reflects a receptor-site phenomenon rather than an abnormal drug disposition.

Plasma noradrenaline, platelet alpha 2-adrenoceptors, and functional scores during ethanol withdrawal

Plasma noradrenaline and platelet alpha 2-adrenoceptor density (sites/cell using 3H-rauwolscine with and without phentolamine) were correlated with withdrawal score in 23 hospitalized patients undergoing ethanol withdrawal. Control groups for plasma noradrenaline were 25 patients admitted to hospital for elective gastroscopy and 12 laboratory workers accustomed to venipuncture. Controls for platelet alpha 2-adrenoceptor measurements were a separate group of 31 normal subjects with a mean age close to that of the patients' withdrawing from ethanol. Plasma noradrenaline was significantly higher in the patients undergoing ethanol withdrawal than in patients admitted to hospital for elective endoscopy. Twelve laboratory controls had plasma noradrenaline levels significantly lower than either patient group. A significant though poor statistical correlation existed between ethanol withdrawal score and simultaneously determined plasma noradrenaline level. Platelet alpha 2-adrenoceptor sites/cell were reduced in ethanol withdrawal compared with the normal controls. Platelet alpha 2-adrenoceptor sites/cell increased over the first 24 hr of ethanol withdrawal but remained significantly lower than control values. The change in platelet adrenoceptors was accompanied by a fall in mean plasma noradrenaline. Thus, the stress of hospital admission itself is associated with an increase in plasma noradrenaline, but ethanol withdrawal enhances this increase, which is accompanied by and probably causes a reduction in platelet alpha 2-adrenoceptor numbers. These changes begin to return towards normal within 24 hr as the withdrawal reaction subsides.

Assessment of diazepam loading dose therapy of delirium tremens

The efficacy of the diazepam loading dose method of treatment of delirium tremens was assessed in comparison with the traditional therapy. The experimental group and the control group comprised 51 and 45 patients respectively. The clinical institute withdrawal assessment for alcohol (CIWA-A) scale was applied to assess the intensity of the symptoms. Diazepam doses in the experimental group oscillated from 40 to 210 mg (mean 86.9 +/- 47.2 mg). The control group was receiving diazepam and other psychotropic drugs in divided doses. In the experimental group deliric symptoms were present from 2 to 24 h (mean 6.9 +/- 4.8 h), and in the control group from 2 to 123 h (mean 33.8 +/- 25.7 h). The results show a large efficacy of the loading dose method corresponding to substantial reduction of the psychosis duration (fivefold in comparison to the control group). The method proved to be safe, with no significant complications.

Alcohol withdrawal syndromes in the human: comparison with animal models

Alcohol withdrawal syndromes in humans lie on a continuum of increasing severity, from the acute hangover to delirium tremens. Early mild reactions consist primarily of hyperexcitability phenomena such as tremor, insomnia, hyperreflexia and hyperventilation. In more severe degree, the same process gives rise to hallucinations and seizures. These early reactions are mimicked closely by alcohol withdrawal signs in experimental animals. Late reactions in humans are characterized by marked sympathetic nervous system overactivity, profound disorientation and hallucinations. Analogous reactions have not yet been observed clearly in other species. The problem may be one of finding appropriate techniques for detecting such changes, rather than a true species difference in their occurrence.

Alpha-atrial natriuretic peptide, aldosterone secretion and plasma renin activity during ethanol withdrawal: a correlation with the onset of delirium tremens?

It is well established that changes in fluid and electrolyte homeostasis may accompany and are likely to modify the clinical symptoms of alcohol withdrawal reactions. It was of obvious theoretical and practical interest, therefore, to investigate the changes in the secretion of hormones which regulate the fluid and electrolyte homeostasis [alpha-atrial natriuretic peptide (alpha-ANP), aldosterone (ALDO) and plasma renin activity (PRA)], together with the changes in the serum electrolytes (sodium, potassium) in male chronic alcoholic inpatients. The patients were transferred to the hospital because of severe alcohol withdrawal reactions. Blood samples were taken on Day 1 (severe withdrawal) and Day 10 (partial recovery from withdrawal) of hospitalization. The peptide and steroid hormones were measured with RIA (radioimmunoassay), while flame photometry was used to measure the electrolytes in the serum. At the time of hospital admission, there was an increased PRA and ALDO level observed. Ten days later, the elevated PRA and ALDO levels were greatly reduced and thus they were back to the normal range. In 60% of the patients, delirium tremens has gradually developed during the observation period. In these patients, an elevated level of alpha-ANP was observed at the time of hospital admission, i.e., days before actual onset of delirium tremens. It is concluded that the disturbed volume homeostasis and the consequently altered alpha-ANP secretion might be associated with and therefore used as an indicator of the onset of delirium tremens.

D-fenfluramine-induced prolactin responses in postwithdrawal alcoholics and controls

Serum prolactin response to the serotonin agonist D-fenfluramine were measured in 19 DSM-111-R male alcoholics, 2.5 or more weeks postalcohol withdrawal. Prolactin responses were compared with nine healthy nonalcoholic male controls. After an overnight fast, each subject received 30 mg of D-fenfluramine orally, and serial samples of serum prolactin were taken over a 4-hr period. D-fenfluramine caused a significantly attenuated peak delta-prolactin response in the alcoholics relative to the controls (p = 0.05). A repeated-measures ANOVA of delta-prolactin yielded a significant within-subjects effect of time (p < 0.05), a within-subjects effect of group that reached significance (p = 0.05), and a nonsignificant group by time interaction. The delta-prolactin value at time points 60 and 240 min postadministration of the probe was significantly attenuated in the alcoholic group, with p < 0.05. There was also some evidence for a diminished serotonergic response in those alcoholics with a negative family history. The delta-prolactin response did not correlate with subjects' age, duration of alcohol use, duration of abstinence from alcohol, severity of alcohol dependence, or age of onset. Results imply a relative subsensitivity of the serotonin system in postwithdrawal alcoholics, and this may be primarily of the 5-HT2 receptor.

Circadian variation in plasma 5-hydroxyindoleacetic acid level during and after alcohol withdrawal: phase advances in alcoholic patients compared with normal subjects

Alcohol withdrawal symptoms in 19 male alcoholics were objectively evaluated and classified and circadian variation in their plasma 5-hydroxyindoleacetic acid (5-HIAA) concentrations was determined at 3 different intervals after cessation of drinking. Circadian variations in plasma 5-HIAA level exhibited phase advances in alcoholic patients compared with normal controls and were different depending on the severity of alcohol withdrawal symptoms. Plasma 5-HIAA in patients with delirium tremens showed significantly higher levels during the abstention period, possibly suggesting peculiarity in their serotonergic metabolism.

Alteration of prolactin serum levels during alcohol withdrawal correlates with craving in female patients

Dopaminergic transmission has been suggested to be a main mechanism mediating reinforcement, withdrawal and craving in alcohol dependency. Dopamine is associated with prolactin secretion, acting as a prolactin inhibitor. The aim of the present study was to investigate whether there is an association between altered prolactin levels and craving during early and late alcohol withdrawal. Therefore, we examined 145 patients suffering from alcohol dependency after admission to the detoxification unit, assessing craving with the Obsessive Compulsive Drinking Scale (OCDS) and measuring prolactin serum levels during early withdrawal (-EW: day 0 or day 1) and late withdrawal (-LW: day 7-day 10). We observed a significant influence of the alteration of prolactin during withdrawal on craving in female patients (Spearman's rho, OCDS-EW: r=-0.607, p=0.001; OCDS-LW: r=-0.730, p<0.001; n=26). The association between prolactin alteration in percentage and craving in females was confirmed with general linear models (OCDS-EW: F=15.819, p=0.001, r(2)=0.530; OCDS-LW: F=17.091, p<0.001, r(2)=0.535). In male patients we did not find any significant results. Our findings support the previously described role of the hypothalamic-pituitary-adrenal (HPA) axis in the neurobiology of alcohol craving and show evidence of an association between increased prolactin serum levels and lower craving during alcohol withdrawal in female patients.

Circadian variation in plasma homovanillic acid level during and after alcohol withdrawal in alcoholic patients

Alcohol withdrawal symptoms in alcoholics were objectively evaluated and classified into three groups according to the severity of their symptoms, and circadian variation in their plasma homovanillic acid (HVA) concentrations was determined at three different intervals after cessation of drinking. The subjects studied were 19 male alcoholic patients and five age-matched healthy male volunteers. Circadian variation in plasma HVA was compared between each patient group and the control group by two-way ANOVA. In the sympathetic overactivity (SO) group comprising nine patients and in the clouding of sensorium (CS) group comprising five patients, plasma HVA concentrations on the 2nd and 3rd day and on the 6th and 7th day after cessation of drinking were low but recovered almost normal levels on the 21st and 22nd postcessation day. The delirium tremens group (DT) comprising five patients, however, showed significantly higher plasma HVA than the control group except on the 6th and 7th postcessation day. The higher plasma HVA in the DT group indicates that there is some sort of preparatory state whereby dopamine metabolism is involved in the appearance of hallucinations at alcohol withdrawal and can possibly be used as a predictor of otherwise hardly predictable delirium tremens.

Platelet MAO during the alcohol withdrawal syndrome

The authors explored platelet MAO activity in alcoholism and focused on the impact of the alcohol withdrawal syndrome on MAO values. They found that platelet MAO activity is relatively increased in alcoholic patients who are experiencing withdrawal symptoms from alcohol and that it does not appear to be stable during the period of withdrawal.