Alcohol: withdrawal + thiamine deficiency

Question 1

What is a common cause of alcohol withdrawal?

Answer 1

Iatrogenic - patient stuck in hospital

Question 2

When does simple alcohol withdrawal present?

Answer 2

6-12 hours after last drink

Question 3

How does simple alcohol withdrawal present?

Answer 3

1) Insomnia
2) Tremor
3) Anxiety
4) Agitation
5) N&V
6) Sweating
7) Palpitations

Question 4

When does alcohol hallucinosis present?

Answer 4

12-24 hours post drink

Question 5

How does alcohol hallucinosis present?

Answer 5

Hallucinations of visual, tactile or auditory origin

Question 6

When does delirium tremens present?

Answer 6

48-72 hours post-drink

Question 7

How does delirium tremens present?

Answer 7

1) Delusions + visual hallucinations
2) Confusion
3) Seizures
4) Tachycardia
5) Hypertension
6) Hyperthermia

Question 8

What are indications for inpatient withdrawal?

Answer 8

1) Patients drinking >30 units per day
2) Scoring > 30 on the SADQ score
3) High risk of alcohol withdrawal seizures (previous alcohol withdrawal seizures or delirium tremens, or history of epilepsy)
4) Concurrent withdrawal from benzodiazepines
5) Significant medical or psychiatric comorbidity
6) Vulnerable patients
7) Patients under 18

Question 9

When is assisted alcohol withdrawal required?

Answer 9

1) Drinking > 15 units per day
2) Scoring > 20 on the AUDIT

Question 10

How is assisted alcohol withdrawal carried out?

Answer 10

1) Chlordiazepoxide is prescribed in a reducing regimen in accordance with the CIWA score + local protocol
2) Pabrinex (1 pair of ampoules daily to prevent WE)

Question 11

What is the first line treatment of an alcohol-withdrawal seizure?

Answer 11

IV lorazepam (rapid-acting benzodiazepine)

Question 12

What should patients on assisted alcohol withdrawal be prescribed if there are any signs of WE (confusion, ataxia, ophthalmoplegia or nystagmus)?

Answer 12

2 pairs of Pabrinex ampoules TDS

Question 13

What is first-line treatment for delirium tremens?

Answer 13

Oral lorazepam

Question 14

What is second-line treatment for delirium tremens if oral lorazepam is declines or symptoms persist?

Answer 14

Parenteral lorazepam

Question 15

What causes Wernicke’s encephalopathy (WE)?

Answer 15

Thiamine (B1) deficiency

Question 16

What causes WE?

Answer 16

1) Chronic alcohol abuse
2) Malnutrition
3) Bariatric surgery
4) Hyperemesis gravidarum

Question 17

How does WE present?

Answer 17

Triad of ataxia + confusion + ocular abnormalities

Question 18

What ocular abnormalities can occur in WE?

Answer 18

1) Gaze-evoked nystagmus
2) Spontaneous upbeat nystagmus
3) Horizontal or vertical ophthalmoplegia

Question 19

How is WE treated?

Answer 19

IV Pabrinex (high dose IV thiamine)

Question 20

What can WE progress to if left untreated?

Answer 20

Korsakoff’s syndrome

Question 21

What is Korsakoff’s syndrome?

Answer 21

This affects the mammillary bodies to cause irreversible deficits in anterograde and retrograde memory

Question 22

How does Korsakoff’s syndrome present?

Answer 22

1) Profound anterograde amnesia with limited retrograde amnesia
2) Confabulation - patients fabricate memories to mask the memory deficit

Question 23

What is the pathophysiology of Korsakoff’s syndrome?

Answer 23

1) Korsakoff’s syndrome is thought to be a result of degeneration of the mammillary bodies
2) The mammillary bodies are part of the circuit of Papez which plays a role in memory formation

Question 24

What other medications can be used in to help treat alcohol withdrawal?

Answer 24

Oral acamprosate or naltrexone

Question 25

What are psychosocial management options for patients with chronic alcoholism?

Answer 25

1) Following assisted withdrawal an intensive community programme with psychosocial support and appropriate medication should be initiated
2) For patients with problem drinking or mild alcohol dependence medically-assisted withdrawal may not be required - psychological interventions
(such as CBT) should be offered first line