Best Alcohol Withdrawal Care for Inpatients Still Elusive

Troy Brown

April 11, 2012

April 11, 2012 (San Diego, California) — As many as 1 in 6 hospitalized patients are going through alcohol withdrawal, and there is little research applicable to this patient population.

This makes it difficult to plan care for patients who are often sicker than patients undergoing alcohol withdrawal without comorbidities or concurrent illness.

Kathleen Finn, MD, MPhil, a clinician educator at Massachusetts General Hospital and an assistant professor of medicine at Harvard Medical School in Boston, discussed issues that hospitalists face when caring for these patients here at the Hospital Medicine 2012: Society of Hospital Medicine Annual Meeting.

Alcohol Withdrawal Very Prevalent

In an interview with Medscape Medical News, Dr. Finn said that "we see an awful lot of alcohol withdrawal. If the prevalence is as [studies] indicate, 1 in 6 of our patients is at risk of alcohol withdrawal. We are the group taking care of the highest risk, meaning that anytime someone has comorbidities or concurrent illness, alcohol withdrawal is going to be more severe. For hospitalists, it's a very important issue."

Scant Data

"The data on alcohol withdrawal [were collected] in detox centers on healthy men, so we are in a data-free zone. No one can tell you right now which benzodiazepine to use, whether we should be using other drugs, whether the CIWA [Clinical Institute Withdrawal Assessment] scale is appropriate for inpatients. Right now, there isn't any advice on what they should be doing, but it is something that as a society we ought to think about and actually start to form groups; we all have a lot of these patients. We might need to start doing randomized really come up with...the best treatments for inpatients," said Dr. Finn.

Ian Jenkins, MD, a health sciences associate professor of medicine at the University of Southern California at San Diego, commented on Dr. Finn's presentation. "Studies are unsatisfactory because they are based on patients being treated for detox alone rather than for acute medical problems," he said.

Patient Assessment

The CIWA-Alcohol scale is the most widely used scale. It and the CIWA have limited value in this patient population because they were designed and validated in detox centers on healthy young men without comorbidity or concurrent illness. In addition, they were intended only for use in early withdrawal to identify patients likely to experience delirium tremens.

The CIWA assesses 10 items: nausea and vomiting, paroxysmal sweats, agitation, anxiety, headache, tremor, auditory disturbances, tactile disturbances, visual disturbances, and clouding of sensorium.

Blood Pressure, Heart Rate Less Informative Than Once Thought

Blood pressure and heart rate, still widely used for medication titration in these patients, can be misleading.

Blood pressure does not correlate with severe alcohol withdrawal or with the severity of alcohol withdrawal, said Dr. Finn. In previous studies of this assessment scale, heart rate was only a small predictor of severe alcohol withdrawal — much smaller than any of the 10 identified screening items, she said.

Dr. Jenkins explained that "Dr. Finn helpfully presented data that heart rate and blood pressure are poor predictors of the severity of alcohol withdrawal. This is especially true in the inpatient setting, where alcoholic patients commonly have conditions like untreated hypertension, infection, or bleeding, which may increase heart rate."

Kindling Theory

The kindling theory is an emerging theory about alcohol withdrawal that might steer treatment in a new direction, said Dr. Finn. "It makes sense, in that we all see that each time [patients] withdraw, they get worse.... That raises ethical questions: Every time we have someone in the hospital and they go through withdrawal, are we making their withdrawal worse the next time? It's a theory that hasn't been proven, but it's something to think about as we see these patients," Dr. Finn said.

Dr. Jenkins agrees that kindling might play a role in alcohol withdrawal. "Prevention or early treatment is key because severe withdrawal can cause kindling, resulting in more severe withdrawal for future episodes," he said.

Better Research Needed

"We can extrapolate from studies done on detox patients, but in the hospital, we don't have a lot to back us up," said Dr. Finn.

Most of the studies were not conducted in sick patients, she noted. In addition, delirium can have many causes; it might not necessarily be due to alcohol withdrawal in patients with comorbidities or concurrent illness.

"Research into the optimal management of alcohol withdrawal in our complex patient population with medical comorbidities is sorely needed. Until then, hospitalists should be cognizant of the properties of the different benzodiazepines and possibly [haloperidol] or baclofen, and reassess their patients often, rather than trusting a taper or symptom-triggered protocol to work reliably," said Dr. Jenkins.

Dr. Finn acknowledged that attendees were likely wondering how to proceed with patients undergoing alcohol withdrawal. Because there is no reliable research, she said that what hospitalists are doing now is probably fine until better solutions can be found.

She recommends that hospitalists see these patients frequently and be very vigilant if they are applying a protocol. Heart rate and blood pressure are not good markers for dosing of benzodiazepines, and if the patient is high risk, benzodiazepines should be started early. All possible contributing factors should be considered in patients with delirium, and hospitalists should work with addiction specialists in their own hospitals to develop protocols.

"I generally recommend long-acting benzodiazepines [as needed] — either diazepam or chlordiazepoxide — targeted to control symptoms and guided by frequent reassessment," Dr. Jenkins said. "Exceptions include the elderly and those with liver disease, for whom lorazepam is more appropriate. Patients with seizures may benefit from some benzo up front to reduce their risk," Dr. Jenkins said.

Dr. Finn believes that hospitalists have the biggest investment in identifying the best care for medical inpatients going through alcohol withdrawal. "We own this issue," and the Society of Hospital Medicine should work to conduct research in this patient population, she said.

Dr. Finn and Dr. Jenkins have disclosed no relevant financial relationships.

Hospital Medicine 2012: Society of Hospital Medicine (SHM) Annual Meeting. Presented April 3, 2012.


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