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
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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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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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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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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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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