Showing posts with label Alcohol. Show all posts
Showing posts with label Alcohol. Show all posts

Friday, 8 January 2021

WHO 2012 Guidelines for the Treatment of Alcohol Withdrawal

WHO 2012 Guidelines to treat Alcohol Withdrawal

  1. Clinicians should advise supported withdrawal in patients before beginning treatment.
  2. The World Health Organization recommends benzodiazepines as front-line medication for the management of alcohol withdrawal. 
  3. Long-acting benzodiazepines are superior to shorter-acting ones, except in cases of impaired hepatic metabolism. 
  4. Clinicians should determine the dose and duration individually. 
  5. The duration of benzodiazepine treatment should be 3 to 7 days.
  6. Clinicians should not use antipsychotic medications as stand-alone medications for the management of alcohol withdrawal. 
  7. Advise Benzodiazepines, and not anticonvulsants, following an alcohol withdrawal seizure.
  8. Clinicians should dispense psychoactive medication in small doses.  
  9. Patients at risk of severe withdrawal, or who have concurrent serious physical or psychiatric disorders, or who lack adequate support, should preferably remain in an inpatient setting. 
  10. As part of withdrawal management, we should give all patients oral thiamine. 
  11. Patients at high risk of Wernicke's Encephalopathy (malnourished, severe withdrawal) should be given 3 days of parental thiamine. 

WHO Alcohol Withdrawal Treatment Guidelines

What interventions are safe and effective for the management of alcohol withdrawal, including treatment for alcohol withdrawal seizures and prevention and treatment for acute Wernicke's encephalopathy?

Alcohol withdrawal can be uncomfortable and occasionally life-threatening. Pharmacological management of alcohol withdrawal is an essential component of alcohol dependence. Benzodiazepines (BZDs), non-sedating anticonvulsants, and antipsychotics are commonly used in the treatment of alcohol withdrawal. 

Given that they are all potentially toxic medications, what is the evidence that the benefits of their use justify the risks? Which is more effective?

Below, I summarize the WHO 2012 Guidelines to treat Alcohol Withdrawal that explains the answers to these questions. 

Thursday, 7 January 2021

Best Choice of Treatment for Delirium Tremens

This topic has moved to the main topic on Delirium Tremens

Clinical Vignette: Preventing Complication in A Man with Agitation

Clinical Vignette: Preventing Complication in A Man with Agitation

A 30-year-old man, who is a heavy alcohol drinker, presented to the emergency department with agitation, altered sensorium, marked tremors, visual hallucinations. On assessment, he is unaware of the time, place, and person. His blood pressure and pulse were 160/11 and 115/min on arrival but fluctuated on monitoring. A GP had given him haloperidol IM and diazepam IV to control his behavioral disturbance. 

What treatment-complication could arise?

a)       Seizures
b)      Over-sedation
c)       Respiratory depression
d)      Arrhythmia
e)       Worsening agitation

Benzodiazepines for the Treatment of Catatonia
Safest Treatment Option for Delirium Tremens
WHO Alcohol Withdrawal Treatment Guidelines

Disulfiram-like reaction

Disulfiramlike Reaction

Disulfiram irreversibly inhibits aldehyde dehydrogenase, by competing with nicotinamide adenine dinucleotide at the cysteine residue. Aldehyde dehydrogenase is a hepatic enzyme of alcohol metabolism converting ethanol to acetaldehyde. At therapeutic doses of disulfiram, alcohol consumption causes elevated serum acetaldehyde, causing manifestations given below.


Facial flushing

We call this constellation of symptoms the disulfiram-alcohol reaction; it discourages alcohol intake. The severity of the reaction is proportional to the dose of disulfiram, and that of alcohol. It is NOT an anti-craving drug and DOES NOT affect the neurobiology of addiction.

NICE guidelines on the Use of Disulfiram

Disulfiram should be considered in combination with a psychological intervention for patients who wish to achieve abstinence, but for whom acamprosate or naltrexone is not suitable. Treatment should be started at least 24 hours after the last drink and should be overseen by a family member or a carer. Monitoring is recommended every 2 weeks for the first 2 months, then monthly for the following 4 months. Medical monitoring should be continued at 6 monthly intervals after the first 6 months. Patients must not consume any alcohol while taking disulfiram

Friday, 17 June 2016

Psychiatric Disorders Associated with Alchoholism

Psychiatric Disorders Associated with Alcoholism

I use the following mnemonic to remember the disorders associated with alcoholism.


  1. Bipolar affective disorders
  2. Anxiety disorders especially panic and social phobia
  3. Depressive disorders, the delusion of infidelity 
  4. Schizophrenia and sexual dysfunction 

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