alcohol misuse Flashcards by Sarah Ramsbottom

problems that alcohol abuse can lead to

psychological - depression
accidents/trauma
physical illness
- acute pancreatitis
- liver cirrhosis
- cancer
- heart disease
criminal activity
domestic violence

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What is 1 unit of alcohol equivalent to?

10ml or 8g of pure alcohol

amount that can be processed in an hour

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alcohol recommended limits

not more than 14 units a week
spread over 3+ days
several drink-free days a week

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How does alcohol work/cause withdrawal?

causes sedation: causes down regulation in inhibitory GABA receptors and up regulation of excitatory neurotransmitter receptors (glutamine, 5HT)
abruptly stopping removes sedative effect but changes in brain persist leading to withdrawal symptoms
time taken for brain to re-establish normal brain neurotransmission determines duration of the withdrawal

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usual time for withdrawal symptoms to occur

within 6-12hrs of last drink

most severe after 48-72hrs

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symptoms of alcohol withdrawal

tremor
sweating
anxiety/irratibility
N&V
sleep disturbances
headache
confusion
seizures
death

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assessment tools of alcohol dependence

AUDIT - 10 Q tool
AUDIT-C - quick screening tool when time limited (A&E), 3 Q
- > only full AUDIT if AUDIT-C >5 (>3 O65)
SADQ - severity of alcohol dependence
CIWA-Ar - clinical institute withdrawal asssessment of alcohol scale revised - severity of WD as part of symptom triggered regimen

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how to assess severity of alcohol dependence

SADQ severity of alcohol dependence questionnaire

assess severity of dependence (mild/mod/severe)
to determine need to assisted withdrawal

CIWA-Ar clinical institute withdrawal assessment of alcohol scale revised - assess severity of withdrawal as part of a symptom triggered withdrawal regimen

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How to manage alcohol withdrawal in community?

mild/mod dependence
planned detoxification with psychological support
fixed dose medication regimen using long acting benzodiazepine
initial dose based on severity SADQ
reduce dose over 7-10 days
monitor pt every 2nd day, involve family/carer
prescribe for installment dispensing, no more than 2 days supplied

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benzodiazepines used in community alcohol withdrawal

chlordiazepoxide

diazepam

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What drug is not used in community setting?

clomethiazole

-> risk of overdose and misuse

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management of alcohol withdrawal in hospital/inpatient setting

planned if community detoxification not appropriate
can be unplanned
fixed dose or symptom triggered medication regimens

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When can unplanned hospital alcohol withdrawal occur?

admitted with illness and no access to alcohol
admitted in acute alcohol withdrawal
often don’t want to stop drinking

aim = prevent complications of withdrawal until discharged

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symptom triggered medication regimen

patient assessed regularly using tool like CIWS-Ar
scores based on symptoms
dose of BDZ PRN

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advantages of symptom triggered med regimen

effective treatment with lower BDZ doses and shorter duration than fixed dose regimens
avoid over/under sedation

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disadvantages of symptom triggered med regimen

requires close and regular supervision (time consuming)

- required trained staff (specific wards)

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drug used for symptom triggered med regimen

chlordiazepoxide (benzodiazepine)

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eg of symptom triggered med regimen

chlordiazepoxide 50mg PRN according to CIWA score

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deficiency in alcohol dependent patients and reasons

deficient in B vitamins

poor diet
poor absorption
reduced liver storage
increased demands

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problems with Vit B deficiency in alcohol dependent patients

thiamine (B1) deficiency can casue Wernicke’s Encephalopathy (WE - reversible) which can progress to Korsakoff’s psychosis (irreversible)
neuropsychiatric maifestations of WE include nystagmus, confusion, ataxia

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treatment for WE (Wernicke’s encephalopathy)

give parenteral thiamine (IV Pabrinex) for at least 5 days followed by oral thiamine

-> Pabrinex is a combination of B vitamins

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What is the most severe form of alcohol withdrawal?

Study These Flashcards

delerium tremens (DT)

symptoms of delerium tremens

Study These Flashcards

agitation
confusion
paranoia
visual and auditory hallucinations

What is delerium tremens (DT)?

Study These Flashcards

most severe form of alcohol withdrawal
medical emergency
life threatening
specialist inpatient management
severe -> critical care for sedation and ventilation

management of DT (delerium tremens)

- oral lorazepam 1st line (short acting) | - symptoms persist/declines, IV/IM lorazepam/haloperidol

treatment for withdrawal seizures in DT (delerium tremens)

IV lorazepam -> NOT phenytoin

treatment for maintaining abstinence

acamprosate or naltrexone disulfiram (2nd line) -> with psychological interventions eg. CBT

Acamprosate MOA

promotes balance between excitatory and inhibitory NTs glutamate and GABA

Acamprosate dose

666mg TDS - reduced dose if <60kg - > 666mg OM, 333mg lunch and ON

side effects of Acamprosate

``` abdominal pain diarrhoea flatulence nausea sexual dysfunction skin reactions ``` (mostly GI s/e)

Disulfiram MOA

alcohol deterrent irreversible inactivation of liver enzyme ALDH metabolism is blocked and intracellular acetaldehyde conc rises causes DAR - disulfiram alcohol reaction

side effects of DAR (disulfiram alcohol reaction)

``` flushing inc body temp sweating N&V pruritis anxiety dizziness headache blurred vision dyspnoea palpitations hyperventilation ``` -> symptoms can be severe and life threatening

When do DAR symptoms develop?

within 15mins after exposure to ethanol peak within 30mins-1hr gradually subsude over next few hrs

dose of disulfiram

200mg daily | inc up to 500mg daily

caution for disulfiram

alcohol must not be consumed 24hrs before, during treatment and for 14 days after stopping

counselling for disulfiram

- rxns after exposure to small amounts of alcohol (perfumes, aerosols) - aware of signs of hepatotoxicity

progression of alcohol related liver disease

``` healthy steatosis (inflammation) - reversible fibrosis cirrhosis - irreversible HCC (hepato cellular carcinoma) ```

1st sign of achoholic liver disease

- alcoholic fatty liver disease - build up of fats in liver - can develop over a few days of heavy drinking - symptoms rare - 1st sign of harmful drinking reversible if stop drinking (no treatment needed)

2nd stage of alcohol liver disease

- alcoholic hepatitis (build up of biliruben) - alcohol misuse over long period of time - can be reversible if stop drinking depending on severity - can be serious and life-threatening

signs of alcoholic hepatitis

sudden onset of jaundice with/without other signs of decompensated liver disease - ascites - encepthalopathy derrages LFTs - biliruben >50 micromol/L - raised AST and ALT (liver enzymes) - AST/ALT ratio >2

signs of alcoholic hepatitis

sudden onset of jaundice with/without other signs of decompensated liver disease - ascites - encepthalopathy derrages LFTs - biliruben >50 micromol/L - raised AST and ALT (liver enzymes)

ascites

fluid collects in spaces in abdomen

What assess severity of alcoholic hepatitis?

modified maddrey discriminant function (mDF)

therapy for alcoholic hepetitis and when to start treatment

if score >32 (mDF) corticosteroid therapy indicated prednisolone 40mg OD 28 days then stop no response to steroids, consider liver transplant

When not to use steroids for alcoholic hepetitis?

active infection high risk of GI bleed

What is cirrhosis?

liver has significant scarring liver become shars and stops functioning normally chronic, not reversible

ompensated and decompensated cirrhosis

compensated - liver copes with damage and maintains functions decompensated - liver can't function properly and complications develop

What does cirrhosis put pt at inc risk of?

HCC (hepatocellular carcinoma)

other problems with decompensated liver disease

coagulopathy hepatic encephalopathy (HE) ascites oesophageal varices

coagulopathy

``` raised INR (still at risk of clots) prolonged PT ``` -> IV vitamin K

hepatic encephalopathy HE

caused by build up of ammonia (toxic to brain) lactulose 20-30ml TDS - reduces intestinal production/absorption of ammonia rifaximin can be added/alternative if recurrent HE - only if tried lactulose/not tolerated

ascites

casued by Na and water retention due to secondary aldosteronism spironolactone 1st line (aldosteorne antagonist) 100mg daily can add in furosemide 40mg daily titrated up to 160mg (if spironolactone not working)

oesophagea varices (varicose veins in oesophagus)

due to portal hypertension screen for using endoscopy can result in acute upper GI bleed (variceal ahemorrhage) non-selective beta blockers (propranolol) - non-selective because only want peripheral benefits not cardiac

What is monitored for closely in decompensated liver disease?

AKI - can get renal failure - reduce/stop diuretics is getting worse

alcohol misuse Flashcards

(54 cards)