Pharmacological management of alcohol withdrawal and newer medicines

1. PHARMACOLOGICAL
MANAGEMENT OF ALCOHOL
WITHDRAWAL AND NEWER
MEDICINES FOR RELAPSE
PREVENTION
Dr. Prasanna P. Khatawkar
M.B.B.S.,D.P.M.,F.A.G.E.,D.N.B.(PSYCHIATRY)
Consultant Psychiatrist
Aadhar Hospital – Specialty Centre for Psychiatry and De-addiction
Solapur

2. PHARMACOLOGICAL
MANAGEMENT OF
ALCOHOL WITHDRAWAL
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3. TEAM
 PSYCHIATRIST
 PHYSICIAN
 GOOD NURSING STAFF
 COOPERATIVE RELATIVES
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4. SETUP
 SPECIALITY PSYCHIATRY SETUP WITH SOS
MEDICAL / ICU BACKUP
 GENERAL HOSPITAL SETUP WITH ATTACHED
PHYSICIAN AND PSYCHIATRIST
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5. ALCOHOL INTOXICATION STATE
 SAFE ENVIRONMENT
 ADEQUATE HYDRATION AND NUTRITION
 MAINTAIN VITALS AND PHYSIOLOGICAL
HOMEOSTASIS
 THIAMINE
 ANTIEPILEPTICS
 ANTIPSYCHOTICS
 BENZODIAZEPINE AVOIDED IN THIS STATE
 WAIT FOR THE EFFECT TO WAN OFF
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6. ALCOHOL WITHDRAWAL STATE
 ALSO CALLED AS ‘ABSTINENCE SYNDROME’
 IT IS A COMPLEX SYNDROME OCCURING IN
PATIENTS DEPENDENT ON ALCOHOL DUE TO
SUDDEN CESSATION OF ALCOHOL
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7. SYMPTOMS
 CONFUSION
 GENERALISED TREMELOUSNESS
 AUTONOMIC ARROUSAL
 DISORGANISED SYMPTOMS
 PSYCHOMOTOR AGITATION
 INSOMNIA
 PERCEPTUAL DISTURBANCE
 GRAND MAL SEIZURES
 DELIRIUM TREMENS
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8. DURATION
 MAY START ANYTIME WITHIN 6 TO 8 HOURS
AFTER LAST DRINK
 MAY LAST UPTO 96 HOURS
 DEPENDS UPON VARIOUS FACTORS
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9. COMMON MEDICINES
USED IN ALCOHOL
WITHDRAWAL
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10. BENZODIAZEPINES
 LFT’s NORMAL : LONG t ½
(CHLORDIAZEPOXIDE, DIAZEPAM)
 LFT’s DERRANGED : INTERMEDIATE t ½
OR SHORT t ½ ( LORAZEPAM, OXAZEPAM)
 AVOID BENZODIAZEPINES WITH ULTRA SHORT
t ½
 HIGH POTENCY DRUG LIKE MIDAZOLAM CAN BE
HELPFUL FOR IMMEDIATE EFFECT
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11. DOSE CALCULATION FOR
BENZODIAZEPINES
 LFT STATUS
 INTAKE OF ABSOLUTE ALCOHOL
 t ½ OF THE BENZODIAZEPINE USED
 PRESENT CLINICAL STATUS
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12. THIAMINE
 B1 VITAMIN (ANEURIN)
 IMPORTANT ROLE IN VARIOUS CELLULAR
PROCESSES SPECIFICALLY IN CNS
 RDA 1.5 MG
 DEPLETED BODY RESERVES IN ALCOHOLICS
 BOLUS DOSE AND REGULAR PARENTAL DOSE
ESSENTIAL IN ACUTE WITHDRAWAL STATE
 100 MG MAY BE ESSENTIAL FOR 7 DAYS
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13. ANTIEPILEPTICS
ACUTE WITHDRAWAL
 CARBAMAZEPINE
 OXCARBAZEPINE
ANTICRAVING
 TOPIRAMATE
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14. ANTIPSYCHOTICS
 USED IN ALCOHOL WITHDRAWAL AS AN ADD-ON
TO FIRST LINE MEASURES SUCH AS
BENZODIAZEPINES TO CONTROL AGITATION OR
PSYCHOSIS
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15. BETA BLOCKERS
 USED TO REDUCE SIGNS OF AUTONOMIC
NERVOUS SYSTEM HYPERACTIVITY AND AT
HIGHER DOSES, ARRYTHMIAS
 HELPFUL TO REDUCE DOSE OF
BENZODIAZEPINES USED IN THIS PHASE
 NOT FIRSTLINE DRUGS DUE TO THEIR
INEFFICACY IN PREVENTING SEIZURE
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16. ELECTROLYTES
 MAINTAINING PROPER ELECTROLYTE BALANCE
ESSENTIAL FOR GOOD AND SPEEDY OUTCOME
 RAPID CORRECTION TO BE AVOIDED
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17. MAGNISIUM
 MAGNISIUM IS AN IMPORTANT COFACTOR IN
VARIOUS CELLULAR PROCESSES
 HYPOMAGNESEMIA ? IMPORTANT PRECIPITATING
FACTOR FOR ACLCOHOL WITHDRAWAL SEIZURES
 DEPLETIONS CORRECTED ORALLY OR
PARENTALLY
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18. NEWER MEDICINES
FOR RELAPSE
PREVENTION
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19. ACAMPROSET
 AMINO ACID DERIVATIVE OF TAURIN
 HYPOTHESIZED TO HAVE ABILITY TO NORMALIZE
ABERRENT GLUTAMATE SYSTEM
 DOSE – 2 GM / DAY
 CAN BE USED IN LIVER DYSFUNCTION
 CAUTIOUS USE IN DERRANGED RENAL
FUNCTION
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20. NALTREXONE
 OPIATE RECEPTOR ANTAGONIST
 ACTS BY PREVENTING OPIATE RECEPTORS
MEDIATED EUPHORIC AND REWARDING EFFECTS
OF ALCOHOL
 HEPATOXICITY NEEDS TO BE MONITERED
 DOSE : 25 – 100 MG – DAILY INITIALY
:50 MG ON ALTERNATE DAYS - LATER
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21. SSRI’s
 SEROTONIN KNOWN TO MODULATE
BEHAVIOURAL EFFECTS OF ALCOHOL
 HELPFUL MAINLY FOR REDUCTION OF SHORT
TERM ALCOHOL USE
 HELPFUL FOR PATIENTS HAVING COMORBID
ANXIETY AND DEPRESSIVE DISORDERS
 ALL SSRI’s FOUND TO BE HELPFUL
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22. DISULFIRAM
 CHEMICAL DETERENT (AVERSIVE AGENT)
 INHIBITS ALDEHYDE DEHYDROGENASE
 USED TO PREVENT IMPULSIVE DRINKING
 NEVER USE WITHOUT KNOWLEDGE AND
CONSENT OF THE PATIENT
 MULTIPLE ADVERSE EFFECTS
 DOSE : 250 TO 500 MG / DAY
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23. BACLOFEN
 DERIVATIVE OF GABA (AGONIST FOR GABA-B
RECEPTORS)
 USED FOR SPASTICITY
 NEWER USE AS AN ANTICRAVING AGENT FOR
ALCOHOL AND COCAIN
 CAN CAUSE WITHDRAWAL SYMPTOMS
 DOSE : 10-20 MG / DAY
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24. OTHER MEDICINES
 LITHIUM
 TCA’s
 5HT-3 ANTAGONIST (ONDENSETRON)
 METRONIDAZOLE
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25. CHOICE OF
BENZODIAZEPINE,
ANTIEPILEPTIC AND
ANTIPSYCHOTIC
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26. IF NO IMPROVEMENT IN 72
HOURS……
 HYPOMAGNESEMIA
 HEAD INJURY
 INCREASED LEVELS OF AMMONIA
 POLYSUBSTANCE USE
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27. COMMON MISTAKES
 NOT USING THIAMINE
 USE OF IV DEXTROSE WITHOUT USING
THIAMINE
 RAPID CORRECTION OF ELECTROLYTES
 IF PATIENT HAS FEVER AVOID INJECTION
HALOPERIDOL
 SUBTHERAPUTIC DOSE OF BENZODIAZEPINES
TO BE AVOIDED
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28. RESTRICTION OF PHYSICAL
ACTIVITIES
 ESSENTIAL IN INITIAL FEW DAYS
 PROPER CONSENT ESSENTIAL
 WATCH FOR FINGER-TIP INJURIES
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29. THANK YOU
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