Subacute Care Forum

Managing Alcohol Withdrawal

In subacute patients experiencing alcohol withdrawal, the consultant pharmacist can glean considerable information from the case history and make key recommendations for improving patient care.

Case History

The patient in this case study (see sidebar on page 284) has a history of alcohol abuse; the problem list indicates seizure disorder and pancreatitis, both of which can be alcohol- induced. During hospitalization, no seizures were noted; the patient may have suffered from alcohol withdrawal seizures in the past. Laboratory test results showed that the patient was not in end-stage alcoholism. Although the presence of liver enzyme concentrations within normal limits implies normal function, patients with severe liver dysfunction may have normal levels because of the small amount of functioning tissue remaining. Protein synthesis would then be greatly altered, as reflected in an elevated International Normalized Ratio (INR) and low serum albumin. INR results were not available for this patient, but the albumin level was normal. Note that the hemoglobin and hematocrit results did not reflect a macrocytic anemia. Patients with alcoholism may be malnourished, as evidenced by low body weight, low serum albumin, and macrocytic anemia secondary to vitamin B12 deficiency. Thus, the patient had maintained some nutritional intake despite his heavy consumption of alcohol. The currently prescribed vitamins were important because they provided thiamine and folic acid, deficiencies of which are linked to complications of alcohol use.

Stages of Alcohol Withdrawal Symptoms

Four stages of alcohol withdrawal symptoms can occur after alcohol consumption is stopped abruptly:

• Stage I occurs six to eight hours after the last ingestion and consists of tremors and anxiety.
• Stage II occurs 10 to 30 hours after last ingestion, and the patient may show signs of insomnia, hallucinations, and hyperactivity.
• Stage III may be evidenced by generalized seizures in 3 percent to 5 percent of patients.
• Stage IV includes delirium tremens (DTs).

DTs manifest with anxiety, sweating, increased pulse and temperature, and cognitive impairment including hallucinations. Treatment with benzodiazepines is standard, but other drugs have been used as well. Chlordiazepoxide, diazepam, and lorazepam are equally effective and are available through oral and injectable routes. The first two drugs have a long-acting metabolite, which extends sedation, but absorption of each after intramuscular injection is unreliable.

Treating Alcohol Withdrawal

Four-day regimens of decreasing doses of these agents can be found in standard texts. For chlordiazepoxide, 50-100 mg q 6-8 h is recommended on day one, followed by 50-100 mg q 8 h on day two, 50-100 mg q 12 h on day three, and 50-100 mg h.s. on day four.¹ the patient's hospital admission began six days ago; apparently no signs of alcohol withdrawal were seen during that time. the patient most likely will not have AWSS now. The dose of chlordiazepoxide is reasonable to treat any symptoms that might emerge without predisposing the patient to unnecessary toxicity.

Some experts believe fixed dosing of benzodiazepines subjects patients to sedation and hospital stays that may not be needed, and that a more individualized treatment with medication given "as needed" is more appropriate. A study by Saitz et al.² concluded that individualized, symptom-triggered treatment is as effective as fixed-dose regimens and uses less benzodiazepine with a shorter treatment duration. Although the benzodiazepines are first-line agents, others have been tried. Carbamazepine was found superior to oxazepam in reducing AWS in one study. One patient had a seizure in the oxazepam group versus none in the carbamazepine group.³ Recommended doses for carbamazepine are 200 mg q.i.d. for seven days, tapered off during the second week. Clonidine reduces tremor, anxiety, tension, and sweating and was superior to placebo in clinical trials, but it has not been compared with any benzodiazpine in clinical trials.⁴ Beta-blocking agents have not proven useful, and phenothiazines are indicated only when psychotic symptoms are present.

Conclusion

Overall, the patient seems at low risk for developing AWSs. The current regimen of vitamin supplementation and as-needed chlordiazepoxide seemed reasonable, and no changes were warranted. The patient should be monitored for pain and AWSs. The consultant pharmacist should note the amount of narcotic used, in addition to whether any chlordiazepoxide was being used, since overuse may lead to sedation, possibly impairing the rehabilitation progress.

Janet Clark, PharmD candidate
College of Pharmacy
University of Arizona
Tucson, AZ 85721

References

1. Bird RD, Makela EH. Alcohol withdrawal: what is the benzodiazepine of choice? Ann Pharmacother 1994; 28:67-71.

2. Saitz R, Mayo-Smith MF, Roberts MS et al. Individualized treatment for alcohol withdrawal. JAMA 1994; 272:519-23.

3. Stuppaeck RP, Miller PC, Oberbauer WH et al. Carbamazepine versus oxazepam in the treatment of alcohol withdrawal: a double-blind study. Alcohol Alcoholism 1992; 27(2):153-8.

4. Erstad BL, Cotugno CL. Management of alcohol withdrawal. Am J Health-Syst Pharm 1995; 52:697-709.

Case Presentation: Alcohol Withdrawal

WS: Needs rehabilitation following foot amputation.

HPI: WS, a 57-year-old homeless man, was admitted to the long-term care facility for rehabilitation and observation after a partial left foot amputation, which resulted from his foot getting caught in railroad tracks. Discharge instructions after the five-day stay called for bearing no weight on left foot and observation for alcohol withdrawal signs, as alcohol abuse had been noted.

PMH: Alcoholism, seizure disorder, and pancreatitis. WS is homeless, smokes one pack of cigarettes per day, and has noted alcohol abuse.

PR: Current medications include one prenatal vitamin daily with 100 mg thiamine daily, oxycodone/acetaminophen 1-2 q 4 h p.r.n. pain, and chlordiazepoxide 25-50 mg q 6 h p.r.n. delirium tremens. Laboratory results from late in the hospital stay were as follows: Na 149 meq/L, K 4.8 meq/L, Cl 109 meq/L, CO2 content 30 meq/L, BUN 18 mg/dL, creatinine 1.2 mg/dL, glucose 92 mg/dL. CBC results show WBC of 9,800/mm3, Hgb 10.7 g/dL, Hct 31.1 percent, MCV 92 fL. Liver function tests and albumin WNL.

SH: Homeless.

ROS: Not available.

PE: No significant abnormalities. The patient is 5' 4" and weighs 140 lbs. On interview, the patient was alert, oriented, and had no specific complaints.

Labs: Not available other than as reported in PMH.

Other: None.

Abbreviations used: WS = chief complaint, HPI = history of present illness, PMH = past medical history, PR = pharmacist review, SH = social history, ROS = review of systems, PE = physical examination, Labs = laboratory values.

The Subacute Care Forum is published monthly. This column contains practice tips, news, and other information that can help consultant pharmacists provide pharmaceutical care to those increasingly common long-term care patients needing a higher level of care and more complex therapies. Contributions, always welcome, should be sent to Academics Editor L. Michael Posey, P. O. Box 6565, Athens, GA 30604; 706/613-0100, 706/613-0200 (fax), mposey@aol.com (e-mail).

Occasionally published in the Subacute Care Forum are case studies, coordinated by Contributing Editor Marie E. Gardner, PharmD, FASCP, of the University of Arizona College of Pharmacy. These case studies provide interesting clinical situations and brief reviews of involved disease states relevant to subacute care and consultant pharmacy.