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Alcohol Use Disorder

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Alcohol Use Disorder Alcohol Use Disorder Alcohol withdrawal Postwithdrawal treatment Mild withdrawal Moderate to severe withdrawal symptoms (CIWA <15) symptoms (CIWA ≥15) Does patient meet Ambulatory alcohol No Evaluate and treat 12 step Other options: principal criteria for ambulatory Inpatient detox withdrawal criteria commorbid mood disorder program SMART, WFC, etc. alcohol withdrawal? Yes No prior history of Hx seizures or delirium tremens, seizures or delirium tremens Consider ambulatory medical comorbidities Pharmacotherapy alcohol detoxification Does patient have subgroup Daily contact with patient; indication/contraindication? daily CIWA MVI + Thiamine Reasonable option in mild withdrawal Hepatic impairment Opioid use Not shown to reduce risk of No (acute hepatitix, LFT ≥3x ULN, Benzodiazepine Gabapentin delirium tremens liver failure) Equal to Benzodiazepines Does patient have No Yes in mitigating withdrawal Clinically indicated opioid use Acamprosate hepatic impairment? Naltrexone symptoms with plans to continue opioid? (avoid in CrCl <30) Chlordiazepoxide No Yes Diazepam Benzodiazepine Lorazepam Abstinence Yes achieved? Lorazepam No Fixed dose regimen generally recommended in Acamprosate ambulatory setting Naltrexone trialed? trialed? Maintenance therapy; typically 3-7 days Yes continue minimum Yes 1 year Ambulatory alcohol detoxification successfully achieved? Trial Acamprosate Trial Naltrexone if no contraindications if no contraindications No Yes Determine etiology of failure; See postwithdrawal consider retrial of above; Yes treatment Abstinence achieved? consider inpatient detox No Disulfiram Topiramate Consider in highly motivated patients Caution in patients with social support; taking Hydrochlorothiazide, contraindicated in cardiac disease, psychosis, Metformin, Valproic Acid ongoing alcohol use ALCOHOL USE DISORDER mu-Opioid Naltrexone DOSING: Start and maintain dose of 50mg QD. ReVia SIDE EFFECTS: (common) headache, nausea, vomiting, somnolence; (rare, serious) Black box Receptor warning for hepatocellular injury (Vivitrol is LAI Antagonist NOTE: FDA-approved for alcohol dependence. Contraindicated in liver failure, hepatitis, patients formulation) taking opioids. Also available in LAI formulation. Glutamate Acamprosate DOSING: Start and maintain dose of 666mg TID. In patients with creatinine clearance between 30 Multi-Modal Campral and 50, give 333mg TID. SIDE EFFECTS: (common) diarrhea (transient), weakness, anxiety, insomnia, peripheral edema; (rare, serious) acute renal failure, suicidal ideation/ attempts/ completions NOTE: FDA-approved for alcohol dependence. Contraindicated in renal dysfunction (creatinine clearance < 30). Aldehyde Disulfiram DOSING: Start 125mg QPM (must be abstinent from alcohol >12 hours), increase to 250mg QPM Dehydrogenase Antabuse after several days. Maintenance is between 250mg and 500mg QPM. SIDE EFFECTS: (common) skin eruptions, drowsiness, impotence, headache, metallic taste; (rare, Inhibitor serious) hepatitis, hepatic failure, psychosis, optic neuritis, peripheral neuropathy NOTE: FDA-approved for alcohol dependence. Contraindicated in heart disease, psychosis, current drinking. Used for aversion therapy; causes unpleasant symptoms when taken with alcohol (flushing, nausea, vomiting, palpitations). Inform patient to avoid using medications containing alcohol or foods containing ethanol. Use only in highly motivated patients with strong support/ psychotherapeutic treatment. mu-Opioid DOSING: See agent descriptions. Topiramate DOSING: Start 25mg QPM x one week; week 2 50mg Receptor Topamax QPM; week 3 25mg QAM, 50mg QPM; week 4 50mg SIDE EFFECTS: See agent BID; week 5 50mg QAM, 100mg QPM; week 6 100mg Antagonists descriptions. BID; week7 100mg QAM, 150mg QPM; week 8 and thereafter 150mg BID. NOTE: Off-label for alcohol SIDE EFFECTS: (common) somnolence, dizziness, dependence. memory difficulties, confusion, ataxia; (rare, serious) metabolic acidosis, renal stones, osteomalacia NOTE: Avoid using in patients taking HCTZ, metformin, valproic acid. Decreases levels of oral contraceptives. Gabapentin DOSING: Start 1800mg-2400mg/day. Use lower dose Neurontin in patients with renal impairment. Target and max doses have not yet been determined. SIDE EFFECTS: (common) somnolence, dizziness, weight gain, ataxia; (rare, serious) drug reaction with eosinophilia and systemic symptoms (DRESS) NOTE: Has abuse potential, so use with care in this population. Fixed-dose Detoxification Schedule for Ambulatory Alcohol Withdrawal MEDICATION DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 Chlordiazepoxide 50 mg q 6-12 hrs 25 mg q 8 hrs 25 mg BID 25 mg at HS 25 mg at HS Librium Diazepam 10 mg q 6 hrs 10 mg q 8 hrs 10 mg q 12 hrs 10 mg at HS 10 mg at HS Valium Lorazepam 2 mg q 8 hrs 2 mg q 8 hrs 1 mg q 8 hrs 1 mg q 12 hrs 1 mg at HS Ativan Oxazepam 30 mg q 6 hrs 30 mg q 8 hrs 30 mg q 12 hrs 30 mg at HS 30 mg at HS Serax Gabapentin 300 mg q 6 hrs 300 mg q 8 hrs 300 mg q 12 hrs 300 mg single dose — Neurontin.
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