Ethanol withdrawal

Background

• Withdrawal symptoms due to reduced GABA and increased glutamate
• Benzos useful due to cross tolerance at ethanol GABA receptor
• Symptom triggered therapy
  • As effective as fixed dose therapy, but w/ more rapid detox

Diagnosis

1. Reduction in alcohol use that has been heavy and prolonged
2. At least 2 of the following
   1. Autonomic hyperactivity (e.g., diaphoresis, HR>100)
   2. Increased hand tremor
   3. Insomnia
   4. Nausea/vomiting
   5. Transient visual, tactile, or auditory hallucinations
   6. Psychomotor agitation
   7. Anxiety
   8. Grand mal seizures
3. CIWA score
   1. http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/#about-calculator
   2. Start benzo therapy at score of 8. Consider ICU admission with score >20.

Treatment

General

• Benzos
  • Diazepam (Valium) 5-10mg IV (depending on severity)
    • May repeat q5-10min for severe withdrawal (titrated to effect)
  • Lorazepam (Ativan) 1-4mg IV (depending on severity)
    • May repeat q15-20min for severe withdrawal (titrated to effect)
• Beta blockers
  • Improve VS, reduces craving
• Alpha agonists (clonidine)