Guidance on the Treatment of Alcohol and Benzodiazepine Dependence in Adults for Inpatient Units - version 1.1 Incorporating Guidance on the Management of Alcohol Withdrawal and the Prevention of Wernicke-Korsakoff Syndrome RATIFYING COMMITTEE Drugs and Therapeutics Group DATE RATIFIED 24.04.17 with a minor amendment to the We3rnicke's prevention advice - January 2020 NEXT REVIEW DATE April 2020 AUTHORS Dr James Fallon - Consultant Psychiatrist Helen Manuell – Clinical Pharmacist Originally written by Dr Hugh Williams - Consultant Psychiatrist, Hon. Clinical Senior Lecturer (no longer working for the Trust) Summary: This guidance aims to assist inpatient staff in the safe and appropriate prescribing and administration of medicines for adults undergoing treatment for alcohol problems This document is compliant with the NICE clinical guidelines 100 and 115 on alcohol dependence and alcohol-use disorders. If you require this document in another format, ie easy read, large text, audio, Braille or a community language please contact the Pharmacy Team on 01243 623349 (Text Relay calls welcome) 1 CONTENTS Page 1. Management of Alcohol Withdrawal and the Prevention of Wernicke / Korsakoff syndrome. 1.1 Alcohol Withdrawal Syndrome 3 1.2 Pharmacological management of alcohol detoxification 3 1.3 Prevention of Wernicke Korsakoff syndrome 5 1.4 General management 6 2. Pharmacological Management used in Relapse Prevention in alcohol dependence 2.1 Prescribing advice for acamprosate 6 3. Benzodiazepine withdrawal 3.1 Benzodiazepine stabilisation 7 3.2 Doses of benzodiazepines equivalent to 5mg diazepam 8 3.3 Benzodiazepine detoxification 8 4. References 9 Appendices 10 2 1. Management of Alcohol Withdrawal and the Prevention of Wernicke / Korsakoff syndrome. 1.1 Alcohol Withdrawal Syndrome Not all heavy drinkers will experience withdrawal phenomena and there is a wide range in the severity of withdrawal symptoms. In some cases withdrawal may be life threatening. It is therefore important to recognise early clinical features and treat them appropriately. Early withdrawal symptoms occur up to 12 hours after the last drink. They include tremor, sweating, anorexia, nausea, insomnia and anxiety. In moderate withdrawal the signs are more marked and transient auditory hallucinations in clear consciousness may also occur. Withdrawal fits (“rum fits”) can occur at 12 to 48 hours and are more likely if there is a previous history of withdrawal fits or epilepsy. Fits tend to be generalised tonic- clonic (if focal, suspect other causes e.g.head injury) and may occur in bouts. In 30% of cases, fits are followed by delirium tremens. Severe withdrawal / delirium tremens usually develop after 72 hours but can be sooner. Clinical features include; marked tremor, confusion, disorientation, agitation, restlessness, fearfulness, visual and auditory hallucinations, delusions, autonomic disturbances, tachycardia, sweating, fever and dehydration. Persons consuming more than 16 units per day (half to one bottle of spirits per day or equivalent) are particularly at risk. Other risk factors include severe dependence, previous history of DTs, older age and coexisting medical conditions such as infection. 1.2 Pharmacological management of alcohol detoxification Which drug to use? Benzodiazepines are the treatment of choice in the management of alcohol withdrawal. Management Guidelines Alcohol dependent patients that exhibit withdrawal features or are at risk of developing withdrawal should be prescribed benzodiazepines, (i.e. diazepam or chlordiazepoxide). Dosage should be individually titrated and will depend on severity of dependence, withdrawal severity, gender, size, weight, general health and liver function. The following regime for inpatient detoxification is a guideline only: A typical inpatient regime for a severely dependent adult male would be: Day 1: Diazepam, 20 mg qds Day 2: Diazepam, 15-20 mg qds Day 3: Diazepam, 15 mg qds Day 4: Diazepam, 10 mg qds Day 5: Diazepam, 10 mg tds Day 6: Diazepam, 10 mg bd Day 7: Diazepam, 10 nocte Females, the elderly and those with milder dependence / withdrawal should be commenced on a lower starting dose, e.g. diazepam 10-15 mg qds, and reduced accordingly. 3 Alternatively, chlordiazepoxide can be used - (5 mg diazepam is approximately equivalent to 10 - 15 mg chlordiazepoxide). A sample regime for a moderately dependent adult male would be: Day 1: Chlordiazepoxide 30 mg qds Day 2: Chlordiazepoxide, 25 mg qds Day 3: Chlordiazepoxide, 20 mg qds Day 4: Chlordiazepoxide, 15 mg qds Day 5: Chlordiazepoxide, 10 mg tds Day 6: Chlordiazepoxide, 10 mg bd Day 7: Chlordiazepoxide, 10 nocte There may be need for dose flexibility especially during the first 48hrs as dosage is titrated against withdrawal symptoms / over-sedation. Patients should therefore be regularly and closely monitored. In very severe withdrawal, (e.g. DTs), additional ‘as required’ oral doses of diazepam (or IM lorazepam) may be necessary for the first few days. Similarly, dosage will need to be reduced in response to excessive drowsiness or over-sedation. Special caution is necessary in the case of severe liver impairment (eg cirrhosis) as the metabolism of benzodiazepines may be reduced and lead to over-sedation. (Lorazepam or oxazepam may be suitable alternatives to diazepam and chlordiazepoxide in these cases). For withdrawal fits or status epilepticus use rectal diazepam (Stesolid®) 10 mg (in view of risk of respiratory depression with IV route). This dose may be repeated at 15-minute intervals where necessary. In the case of severe behavioural disturbance use oral haloperidol 5-10 mg. However, be aware that use of antipsychotics may lower the seizure threshold. For severe vomiting use metoclopramide 10 mg IM for up to 5 days or cyclizine 50 mg IM. NB. Haloperidol also has anti-emetic action and therefore if used for behavioural disturbance might also combat any nausea and vomiting. If it does not, it should not be used in combination with metoclopramide as this greatly increases the risk of extrapyramidal side effects, instead of cyclizine. What dose to start on? Scores on the Severity of Alcohol Dependence Questionnaire (SADQ) and / or units of alcohol per week can provide a rough guide to deciding the starting dose of benzodiazepines, (i.e. what point to start on the Alcohol Detoxification Prescription Chart *). However, this is no substitute for careful, regular observation and monitoring, especially in the first day or two. *Special prescription forms for prescribing benzodiazepines and vitamin supplements for alcohol detoxification are available. 4 Table 5: Guide to starting dose of benzodiazepines for alcohol detoxification (adult male) MILD MODERATE SEVERE V SEVERE SADQ 15 15-30 30-40 40+ UNITS/WEEK 100 100-200 200+ 250+ Diazepam 5-10mg 10-15mg 20mg 20mg QDS QDS QDS QDS Chlordiazepoxide 10-15 mg 25-30mg 40-50 mg 50mg QDS QDS QDS QDS Severity of Alcohol Dependence Questionnaire (SADQ) (See appendix 1). The Severity of Alcohol Dependence Questionnaire is a self-administered and reliable instrument to measure the severity of alcohol dependence. It can also be used to predict the degree of withdrawal symptoms and help in judging medication. The amount of alcohol consumed per week (units/week) can also give estimate of dependence and likelihood of withdrawal. (See appendices 2 and 3). Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). This scale can sometimes be used to assist in the assessment of withdrawal symptoms and their severity. A simplified version of it can be found on the reverse of the special prescription forms for inpatient alcohol detoxification. Patients should be breathalysed and the first dose of benzodiazepine given if serial readings show a falling alcohol concentration and there is no evidence of gross alcohol intoxication. Caution is needed if the patient shows a high alcometer level (e.g. 0.35mg/L breath alcohol, BrAC). 1.3 Prevention of Wernicke-Korsakoff syndrome Wernicke’s encephalopathy is a common and potentially fatal consequence of alcoholism. Failure to prevent or successfully treat Wernicke’s encephalopathy can lead to the development of Korsakoff’s psychosis, which may be extremely difficult to manage and represents a huge healthcare burden. Wernicke’s encephalopathy (acute confusion, ataxia, ophthalmoplegia) may be difficult to recognise /diagnose as all 3 features are only present in 10% of cases. Vitamin Supplements: It is important to note that oral thiamine is poorly absorbed in alcohol dependent patients. Therefore all patients undergoing inpatient detoxification should receive IM/IV high potency vitamin B complex preparations (Pabrinex®) for five days. On admission, the first dose should be administered before any food is offered. This should be followed by oral thiamine (vitamin B1) 100mg TDS for a minimum of six weeks before reviewing if Wernicke’s encephalopathy and Korsakoff’s psychosis (amnesia, time disorientation and confabulation) are to be prevented. Anaphylactic reactions are rare (1 in 5 million for IM, 1 in 250,000 for IV) but facilities for treating anaphylactic reactions must be readily available whenever IM / IV preparations of vitamin B complex preparations (Pabrinex®) are used. Note: the first dose of parenteral vitamins should be given before the first meal of the day. IM is the more common and preferred route of administration. Pabrinex® IM should be given in divided doses and no more than 4ml volume per injection site. If the IV 5 route is used then drip infusion using 50-100