Download Guidance - Pharmacological alcohol detoxification

Guidance - Pharmacological alcohol
detoxification
Version:
Author:
Designation:
Responsible Director:
Approved By:
Approval Date:
Review Date:
V1
Sarfraz Bolia
Clinical Pharmacist
Medical Director
Mental Health Drugs and Therapeutics Committee
12th November 2015
November 2018
1
CONTENTS
1.
Introduction
2.
Duties / Responsibilities
3.
Definitions of alcohol related harm
4.
Assessment of alcohol intake
5.
Managing withdrawal
6.
Other responsibilities
7.
Development and review
8.
Dissemination
9.
References
10.
Appendices
Appendix 1 – Short Alcohol Dependence Data Questionnaire (SADQ)
Appendix 2 – Clinical institute withdrawal Assessment for Alcohol (CIWA-AR)
2
1. Introduction
1.1 Definition
These guidelines are intended to be used for patients over the age of sixteen years
that are admitted under the Coventry and Warwickshire Partnership Trust Inpatient
services who are suspected to misuse alcohol.
In keeping with NICE guidance on alcohol withdrawal, use is made of objective
screening and rating scales.1 It is important to emphasise that this guidance should
be used to supplement clinical decision making. This guidance is not a substitute for
thorough clinical assessment and clinical judgement may supersede this.
1.2
Aims
To support inpatients who may require and benefit from pharmacological alcohol
detoxification.
2. Duties /Responsibilities
2.1 Staff
These guidelines are used as a reference guide for any appropriately qualified
member of CWPT.
3. Definition of alcohol related harm
3.1 - Alcohol withdrawal symptoms
It is estimated 40% of individuals will develop an acute withdrawal syndrome upon
stopping or significantly curtailing alcohol intake.2 The risk of withdrawal is not
directly related to intake.3 Symptoms are seen within hours (typically 6 to 8) of the
last drink and may develop before the blood alcohol level has fallen to zero. 2, 3
Symptoms outlined below may vary in severity, commonly peaking at 10 to 30 hours
and usually subsiding by 40 to 50 hours.4, 5
Common features
Hand tremor
Minor hallucinations
Insomnia
Anxiety, agitation,
disorientation.
confusion,
Sweating, flushing
Tachycardia
Convulsions
Nausea,vomiting,
anorexia, diarrhoea
Less-common features
Arrhythmia
Hypertension
Paraesthesia
Hepatic dysfunction
Suicidal ideation
The risk of developing severe withdrawal symptoms and progression to delirium
tremens is associated with the presence of the following symptoms. 2, 6
Fever
Hypoglycaemia Insomnia
Sweating
Hypokalaemia
Other psychiatric disorders
Tachycardia
Hypomagnesia Use of concomitant psychotropic drugs or illegal substances
High levels of anxiety Hypocalcaemia Poor physical health
Previous history of severe withdrawal symptoms and or delirium tremens, history of seizures
High alcohol intake (Greater than 15 Units a day for a person of average build)
3
3.2 - Alcohol related seizures
This includes epileptiform seizures (normally grand mal) that usually occur within 12
to 48 hours of alcohol cessation and may develop before the blood alcohol level has
fallen to zero.7 Seizures are rare beyond 48 hours following alcohol cessation.2
Give consideration to seizure history for inpatients suspected of misusing alcohol,
Alcohol will reduce the seizure threshold of patients and may increase seizure
frequency overall. Many anti-epileptic drugs are metabolised through the liver, so
blood levels may need to be checked.
3.3 - Delirium tremens (DTs)
DTs occur in about 5% of patients undergoing alcohol withdrawal but accounts for
the highest morbidity and mortality.8 Untreated, DTs is fatal in 15-20% of patients
whilst early detection and prompt initiation of treatment usually prevents onset.
Appropriate management reduces mortality to around 1%.4 Onset of DTs is 2 to 5
days (most commonly at 3 to 4 days) following cessation and represents a medical
emergency.8 If untreated, death may result from respiratory and cardiovascular
collapse or cardiac arrhythmias. Patients most at risk are those with a high fever
(>104°F/39.9°C), tachycardia, dehydration and an associated illness (e.g.
pneumonia or pancreatitis), general debility or where the diagnosis is delayed. 7 If
Delirium tremens is suspected, please refer the patient to acute medical services.
3.4 - Wernicke’s encephalopathy (WE)
Inappropriately managed WE is the primary contributory cause of death in 17% of
affected patients and results in permanent brain damage in 85% of survivors. Postmortem analysis has demonstrated that WE may occur in as many as 12.5% of
chronic alcohol misusers, although WE or Korsakoff’s psychosis has historically
been diagnosed during life in only 5-20% of patients. The classically described triad
of signs of acute confusion (82%), ataxia (23%) and ophthalmoplegia (29%) actually
occurs in only 10% of patients.9 As a result the triad cannot be used as the basis of a
diagnosis. All patients undergoing alcohol withdrawal should be assessed for
development of Wernicke’s encephalopathy. This includes any patient admitted for
other reasons and may subsequently be found to require detoxification, as well as
those with a known/suspected history of alcohol misuse.8
3.5 – Alcohol detoxification
Alcohol detoxification is also known more accurately as medically assisted
withdrawal from alcohol. This is the process by which the acute alcohol withdrawal
syndrome associated with the cessation of alcohol use for an alcohol dependent
service user is alleviated by medication.
4
4 - Assessment of alcohol intake
4.1 – Severity of Alcohol Dependence Questionnaire
For Patients in whom alcohol dependence is identified or suspected, it may be
helpful to use a SADQ assessment to identify level of dependence. The SADQ
questionnaire [Appendix 1] as recommended within NICE guidance is used to score
the severity of alcohol toxicity. This assessment takes approximately 5 minutes and
covers psychological changes, changes in arousal and perceptual changes of
alcohol withdrawal.1
Scoring Interpretation
Scoring range
Interpretation
One to Nine
Indicates low dependence
Ten to Nineteen
Indicates moderate dependence
Twenty or above
Indicates severe dependence
* SADQ scoring interpretation of dependence severity differs to that advised within NICE
detoxification algorithm; please exercise your clinical discretion to judge dependence.
It is imperative to remember a scoring tool should be used to guide your clinical
judgement. Where the patient has poor understanding or comprehension of the
SADQ assessment, not willing to engage in assessment or they lack capacity, it is
appropriate to assess physical symptoms of withdrawal objectively and treat on the
basis of clinical judgement.
5 - Managing Withdrawal.
5.1 Investigations
Where patients are suspected to be dependent on or abusing alcohol, it is
recommended the following investigations are ordered on initial examination of the
patient. See the CWPT Physical Examination of Admitted Service Users Policy for
further information.
Full blood count and INR
Urea and electrolytes
Liver function tests
Gamma-glutamyl transferase
Thyroid function tests
Lipid profile
Vitamin B12 and folate
Calcium
Magnesium
Phosphate
Glucose
ECG
5
5.2 – Observations
Observations should be carried out regular intervals (at least every six hours).8 The
Temperature, pulse, respiratory rate and blood pressure must be monitored.
Observations may need to be more frequent for patients judged to be at risk of
developing Delirium Tremens or other serious complications. Observations should
be continued for the first twenty four hours from admission and then twice daily for
the duration the patient receives detoxification therapy. CIWA-Ar (Clinical institute
withdrawal Assessment for Alcohol) scoring to guide therapy can be used if
appropriately qualified nursing staff are available [Appendix 2]. The observations are
subject to review by the medical team on an on-going basis.
5.3 – Pharmacological detoxification treatment
Chlordiazepoxide is the benzodiazepine of choice for uncomplicated withdrawal from
alcohol due its low dependence-forming potential. 8 Diazepam may be considered as
an alternative treatment.
The fixed dose treatment regime on Page 7 is recommended by NICE in accordance
with SADQ scores and estimated daily alcohol consumption. 11
Learning disability: When using this regime, please take into account dosing levels
for patients with learning disability may need to be towards the lower end of the
prescribing scale as patients may be on other medication that can depress central
nervous system function. Patients may also be more susceptible to adverse effects
due to compromised physical health. Dosing can also be influenced by a number of
factors such as age, weight, pre-existing medical conditions such as epilepsy, and
liver function. 10, 12
Older People: For older patients avoid chlordiazepoxide.1, 11 An alternative regime
using Lorazepam or oxazepam should be considered: Metabolism is minimally
affected by age and liver disease thus the build up of metabolites and excessive
sedation are less likely to occur. 8 Older adults are more susceptible to the side
effects of benzodiazepines therefore it is recommended that half the dose of
benzodiazepine to that of adults be used.
Oxazepam is the least likely
benzodiazepine to cause respiratory depression thus may be preferred where there
is respiratory co-morbidity. 8
Liver disease: For patients with decompensated liver disease, avoid
chlordiazepoxide.1, 11 An alternative regime using Lorazepam or oxazepam should
be considered as there is lesser risk of drug or metabolite accumulation.
Metabolism may be affected by severity of liver disease thus dose reduction may
also need to be considered. 8
Pregnancy: The research into the safety of benzodiazepines during pregnancy is
limited and it is recommended that use of benzodiazepines during pregnancy should
be based on whether the benefits outweigh the risks. As in any patient who may be
pregnant or is pregnant, each case is dealt with on an individual basis. Please
contact the local obstetrics team for advice.
6
Chlordiazepoxide detoxification regime as recommended by NICE Feb 2010 11
Chlordiazepoxide 25mg is equivalent to Lorazepam 1mg.8
Chlordiazepoxide 25mg is equivalent to Oxazepam 30mg
7
5.4 - Prophylaxis therapy for Wernicke’s encephalopathy.
It is generally advised that Patients undergoing alcohol withdrawal should be
assessed for Wernicke’s encephalopathy.
Where there is risk, prophylactic
treatment should be commenced. This includes anyone admitted for other reasons
that are subsequently found to require detoxification as well as those with a
known/suspected history of alcohol misuse.
Prophylaxis against Wernicke’s encephalopathy
Pabrinex Intramuscular gluteal - 1 pair of ampoules DAILY for 3 to 5 days8
One pair of ampoules is approximately 7ml in volume and thus the injection is likely
to be quite painful and risk of haematoma is significant. If Magnesium serum levels
are low, uptake of Pabrinex is poor. It may be necessary to administer the 7ml from
one pair in two different sites to reduce risk of haematoma and increase uptake.
There is a small risk of anaphylaxis when Pabrinex is administered. Thus the CSM
advises that facilities to manage anaphylaxis must be available where Pabrinex is
used.13 The incidence of anaphylactic reactions to IM Pabrinex is estimated to be 5
cases in 1 million pairs. Physical observation should be taken before and after
administering Pabrinex and patient should be closely monitored for any symptoms or
signs of anaphylaxis.
Thiamine 100mg three times a day plus oral vitamin B compound strong 2 tablets
once a day should be considered after the course of parenteral administration of B
vitamins is completed. 2, 14 Duration of up to one month of oral Thiamine tablets and
vitamin B compound strong tablets is recommended. Continuation is required if the
patient has inadequate dietary intake or there is evidence of secondary cognitive
impairment. 14
5.5 Management of alcohol withdrawal related seizures.
Prophylactic treatment of seizures in patients with a prior history of withdrawal
seizures should be managed with chlordiazepoxide 50mg administered orally upon
presentation, followed by a further 2 doses at 1 hour intervals. 4 Lorazepam can be
used at an equivalent dose where it is drug of choice for detoxification. 10
Withdrawal seizures are usually singular or occur as a brief flurry over a short period.
Withdrawal-associated seizures are generalized tonic-clonic convulsions that usually
occur within 12 to 48 hours after the last drink, but may occur after only two hours of
abstinence. 7 The seizures occur predominantly in patients with a long history of
chronic alcoholism. Although seemingly benign, alcohol withdrawal seizures left
untreated progress to delirium tremens in nearly one-third of patients thus caution
and careful monitoring is urged.7
If status epilepticus occurs, this is managed as below:
Administer appropriate first aid and undertake necessary actions to maintain client’s airway
and general safety in the event of a seizure.
If the seizure continues for longer than 5 minutes administer rectal diazepam, a dose of
between 10 and 20mg is appropriate.
If there are other concerns or difficulties monitoring the patient, or the seizure continues for a
further 5 minutes, please call Emergency services 999.
8
airway, breathing, circulation or other vital signs call the crash team / an
ambulance.
There is little evidence to support the use of antiepileptic drugs in the prophylaxis or
treatment of alcohol withdrawal-induced seizures. 8
5.6 Management of Delirium Tremens.
Refer the patient to acute medical services for optimum patient care. This is
because there is often a coexisting medical condition such as pancreatitis,
pneumonia or other infection and there may be life threatening complications. Mental
Health wards do not have facilities for administering IV fluids thus referral is advised.
Where delirium tremens develops in a patient during treatment for acute alcohol
withdrawal, referral to the general medical setting is necessary, the patient may
require intravenous administration of benzodiazepine, fluids and vitamins. 8
Consider an antipsychotic (caution required due to lowered seizure threshold) in a
patient with delirium who is distressed or considered a risk to themselves or others
and if verbal and non-verbal de-escalation techniques are ineffective and response
to benzodiazepines is poor. Antipsychotic therapy should not be used routinely and
is rarely justified.14 It is normally for short-term only (Less than seven days) unless
there is evidence of underlying thought disorder. The recommended starting dose
for haloperidol for patients with underlying liver disease is 1.5 – 2mg TDS orally. 6
ECG and correction of electrolytes are recommended prior to consideration of
antipsychotic therapy. 8
5.7 Management of Wernicke’s encephalopathy.
The classic triad of ophthalmoplegia, ataxia and confusion is rarely present in
Wernicke’s encephalopathy and the syndrome is much more common than is widely
believed. 4 A presumptive diagnosis of Wernicke’s encephalopathy should therefore
be made in any patient undergoing detoxification who experiences any of the
following signs:






Ataxia
Hypothermia and hypotension
Confusion
Ophthalmoplegia/nystagmus
Memory disturbance
Coma/unconsciousness.
Referral of the patient to acute medical services is necessary. Administration of
intramuscular Pabrinex into multiple sites would be very difficult and painful for the
patient to tolerate, thus intravenous administration of Pabrinex is preferred. The risk
of haematoma is also significant. Mental Health wards do not have facilities for
administering intravenous medication and fluids and these conditions are also often
associated with inter-current illness such as electrolyte imbalance and chest
infection.
9
5.8 Discharge and detoxification regimes.
Ideally the patient should remain in hospital until the withdrawal regime of
chlordiazepoxide is complete. If this is not practical, discharge arrangements should
be discussed with the multidisciplinary team (doctor, nurse, pharmacist, GP). The
likelihood of the patient abstaining from alcohol and the support available to them at
home must be considered. If there is doubt that the patient will remain abstinent after
discharge, then Chlordiazepoxide should not be prescribed to take home.
6 Other responsibilities
6.1 Advice on driving
Service users who drive must be advised they are legally responsible for informing
the DVLA of any condition including alcoholism which impairs ability to drive. If a
patient continues to drive against your medical advice, please advise them of your
duty to disclose their information to the DVLA medical advisers.
7 Development and review
7.1 – Version development
Version Lead Person(S)
1
Sarfraz Bolia
1
Ahmed Elaswed
Designation
Pharmacist
Neuropsychiatrist
Date
Aug 2014
Aug 2014
For review
Aug 2017
Aug 2017
7.2 – Consultation
This guideline has been developed in consultation with
Name
Designation
Organisation
8 Dissemination
This guideline is for use by staff working with adult inpatient services for the
Coventry and Warwickshire NHS Partnership Trust.
These guidelines can also be used as a reference guide for any appropriately
qualified member of CWPT.
10
References
1.
NICE (2011) Alcohol-use Disorders: Diagnosis, Assessment and
Management of Harmful Drinking and Alcohol Dependence. NICE clinical
guideline 115. Available at www.nice.org.uk/CG115 (Accessed 10/01/2014)
2.
Morgan MY & Ritson B. Alcohol and Health 1998. Medical Council on
Alcoholism, London.
3.
Drug and Therapeutics Bulletin, [1991], 29(18): 69-71
4.
Adinoff B et al. Medical Toxicology 1988; 3: 172-196.
5.
Wills S (2005) Drugs of abuse 2nd edition, Pharmaceutical Press, London.
6.
Royal College of Physicians (RCP). Alcohol – can the NHS afford it? Royal
College of Physicians of London 2001.
7.
Hall W & Zador D. Lancet 1997; 349: 1897-1900.
8.
Taylor D, Paton C, Kapur S. "The Maudsley Prescribing Guidelines in
Psychiatry, 11th Edition", Wiley Blackwell, London, 2012.
9.
McIntosh C et. Al. Parenteral Thiamine use in the Prevention and Treatment
of Wernicke’s Korsakoffs Syndrome, Psychiatric Bulletin 2005(29); 94-97.
10.
NICE (2011) Alcohol-use Disorders: Diagnosis, Assessment and
Management of Harmful Drinking and Alcohol Dependence. NICE clinical
guideline 115. Available at www.nice.org.uk/CG115 (Accessed 10/01/2014)
11.
National Institute for Clinical Excellence (2010) Alcohol-use disorders: sample
chlordiazepoxide dosing regimens for use in managing alcohol withdrawal.
NICE clinical guidelines 100 and 115. February 2010.
Available at http://www.nice.org.uk/guidance/cg115/resources/cg115-alcoholdependence-and-harmful-alcohol-use-sample-chlordiazepoxide-dosingregimens-for-use-in-managing-alcohol-withdrawal2 (Accessed 31/07/2014)
12.
Bhaumik, A. and Branford, D. (eds.) (2012). The Frith Prescribing Guidelines
for Adults with Learning Disability. London: Taylor and Francis.
13.
Drug Safety Update September 2007, vol 1 issue 2: 8. Available from
http://www.mhra.gov.uk/SafetyinformationDrugSafetyUpdate/CON079169
14.
Evidence-based guidelines for the pharmacological management of
substance abuse, harmful use, addiction and comorbidity: recommendations
from BAP; British Association for Psychopharmacology (May 2012)
11
Appendix 1
Short Alcohol Dependence Questionnaire (SADQ)
12
Appendix 2
13
Please print the following chart to record observations if CIWA-Ar scoring is to
be used to observe and assess a patient.
14